essay on workplace violence in healthcare

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• v.78; 2022 Jun

Workplace violence in healthcare settings: The risk factors, implications and collaborative preventive measures

Mei ching lim.

a Department of Public Health Medicine, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Jalan UMS, Kota Kinabalu, 88400, Sabah, Malaysia

Mohammad Saffree Jeffree

Saihpudin sahipudin saupin, nelbon giloi, khamisah awang lukman.

b Centre for Occupational Safety & Health, Universiti Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia

Violence at work refers to acts or threats of violence directed against employees, either inside or outside the workplace, from verbal abuse, bullying, harassment, and physical assaults to homicide. Even though workplace violence has become a worrying trend worldwide, the true magnitude of the problem is uncertain, owing to limited surveillance and lack of awareness of the issue. As a result, if workplace violence, particularly in healthcare settings, is not adequately addressed, it will become a global phenomenon, undermining the peace and stability among the active communities while also posing a risk to the population's health and well-being. Hence, this review intends to identify the risk factors and the implications of workplace violence in healthcare settings and highlight the collaborative efforts needed in sustaining control and prevention measures against workplace violence.

• • Workplace violence needs to be addressed more comprehensively, involving shared responsibilities from all levels.
• • Emphasis on healthcare management's commitment, assurance, and clearly defined policy, reporting procedures, and training.
• • The healthcare workers' commitment to update their awareness and knowledge regarding workplace violence.
• • The provision of technical support and assistance from professional organizations, NGOs, and the community.

1. Introduction

Violence affects people at all levels of society and can occur anywhere; at home, on the streets, in schools, workplaces, and institutions. Violence had previously been overlooked as a Public Health issue due to the lack of a clear definition, undeniably a complex and diffused matter. It is not as simple as relating violence to scientific facts to define it; instead, it is a matter of judgment of appropriate and acceptable behaviors influenced by culture, values, and social norms. Violence is determined by the World Health Organization (WHO) as the deliberate use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that has consequences or has a high probability of resulting in injury, death, mental distress, mal-development, or deprivation.

Occupational Safety and Health Administration (OSHA) defines workplace violence as any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at work [ 1 ]. While physical violence (which includes beating, biting, kicking, pushing, slapping, stabbing, and shooting) in the workplace has been acknowledged, little has been done to address the presence of psychological violence until recent years [ 2 ]. Psychological violence is the intended use of power, including the threat of physical force against another person or group with the potential to impair the affected individual's physical, mental, spiritual, moral, or social development [ 2 ]. Besides, harassment which is also categorized as a type of violence, is defined as any behavior that degrades, humiliates, irritates, alarms, or verbally insults another person, including abusive words, bullying, gestures, and intimidations [ 3 ]. This review aims to determine the risk factors and consequences of workplace violence in healthcare settings, as well as emphasizing the joint efforts required to enhance the control and preventative measures of workplace violence.

2. Workplace violence in healthcare settings

Although violence in the workplace affects almost all sectors and groups of workers, it is apparent that violence in healthcare settings provides a significant risk to public health and an occupational health issue of growing concern. The healthcare and social service industries have the greatest rates of workplace violence injuries, with workers in these industries being five times more likely to be injured than other workers [ 4 ]. In addition, workplace violence in the health sector is estimated to account for about a quarter of all workplace violence [ 5 ]. Workplace violence is constantly on the rise in the health industry due to rising workloads, demanding work pressures, excessive work stress, deteriorating interpersonal relationships, social uncertainty, and economic restraints [ 5 ].

Healthcare workers accounted for 73% of all nonfatal workplace injuries and illnesses due to violence in 2018 [ 4 ]. According to World Health Organization (WHO), it is estimated that between 8% and 38% of health workers suffer physical violence at a certain point in their careers. At the same time, many more are exposed or threatened with verbal aggression [ 6 ]. Most violent cases are committed by patients’ family members or friends and followed by patients themselves [ 4 , 7 ]. Violence in healthcare settings worsens when there is a crisis, emergency, or disaster which involves large groups of people who are even more overwhelmed with panic attacks, shock, uncertainties, fears, and worries of the conditions they or their family members are going through [ 6 ]. As a result, healthcare workers become the targets to vent their anger or frustrations. The most vulnerable healthcare workers victimized are staff at emergency departments, especially nurses and paramedics, and staff directly involved with in-patient care [ 5 , 6 ].

Furthermore, the Healthcare Crime Survey conducted by International Association for Healthcare Security and Safety Foundation's (IAHSSF) in 2019 reported the assault rates against healthcare workers increased from 9.3 incidents in 2016 to 11.7 per 100 beds in 2018, which is the highest rate that IAHSSF has ever recorded since 2012 [ 8 ]. 85% of workplace violence occurrences were classified as National Institute for Occupational Safety and Health (NIOSH) Type II Customer/Client Workplace Violence, which involves violence directed at employees by customers, clients, patients, students, inmates, or anybody else for whom an organization provides services [ 9 ]. According to a meta-analysis of 47 observational studies, the overall prevalence of workplace violence against healthcare professionals was 62.4%, with verbal abuse accounting for the highest majority (61.2%), followed by psychological violence (50.8%), threats (39.5%), physical violence (13.7%), and sexual harassment (6.3%) [ 10 ].

Even though some institutions may have a proper formal incident reporting system, there are still many incidents, especially in the forms of bullying, verbal abuse, and harassment, unreported [ 11 ]. Lack of reporting guidelines or policy, lack of trust in the reporting system, and fear of retaliation are among the many reasons for underreporting [ 12 , 13 ]. For example, in Malaysia, with the launching of the guidelines and training modules to address and prevent violence against healthcare workers, more cases were reported with a drastic 159% increase from 167 cases in December 2017 to 432 cases in December 2018 [ 14 ]. The Emergency Department and the Psychiatry and Mental Health Departments were high-risk areas, as they were in other countries, with the most common perpetrators being patients, their relatives, or visitors [ 14 ]. While verbal violence, physical assault, intimidation, and sexual harassment were among the types of workplace violence documented [ 14 ], cyberbullying has been on the rise in recent years, with humiliation, defamation, and unlawful video recording in healthcare settings.

3. Risk factors of workplace violence in healthcare settings

The etiology of workplace violence can be pretty complex, and many risk factors are related to both the perpetrators and the healthcare workers assaulted. The environments under which care and services are provided in healthcare settings contributed to healthcare workers being more prone to occupational violence. Many studies were conducted, and some of the risk or associating factors that contributed to the amplified incidence of violence towards healthcare workers over the recent years are: (i) attitudes and behaviors of patients, family members, friends, or visitors who are often under intense emotional charge and expectations [ [15] , [16] , [17] ]; (ii) healthcare workers and work factors which include shortage of staffs, inexperienced or anxious staffs, poor coping mechanism and lack of training [ [18] , [19] , [20] , [21] , [22] ]; and (iii) system or environmental factors (overcrowded areas, long waiting hours, inflexible visiting hours, lack of information as well as difference of language and culture) [ 15 , 17 , 19 , 20 , 23 , 24 ].

4. Effect of workplace violence in healthcare settings

Violence against healthcare workers in any situation is inexcusable, especially when they are working around the clock to ensure that everyone receives the best treatment possible. The effect of violence harms healthcare employees' physical and psychological well-being of healthcare workers [ 6 ]. Victims of violence are more likely to experience demoralization, depression, loss of self-esteem, ineptitude as well as signs of post-traumatic stress disorders like sleeping disorders, irritability, difficulty concentrating, reliving of trauma, and feeling emotionally upset [ 7 , 17 , 24 , 25 ].

Furthermore, the negative implications of such widespread violence in healthcare sectors have a significant impact on the delivery of health care services, including a decline in the quality of care delivered, increased absenteeism, and health workers' decision to leave the field [ 5 , 15 , 17 , 19 , 25 ]. As a result, the number of health services available to the general public will be limited, resulting in increased healthcare costs due to resource constraints. In addition, if healthcare workers leave their employment due to harassment and threats of violence, equal access to primary health care would be threatened, particularly in developing countries where the number of healthcare workers is insufficient to meet the needs and demands of the population.

Many healthcare employees mistakenly feel that workplace violence is just part and parcel of their jobs [ 26 , 27 ] and that they were unlucky enough to be in the wrong location at the wrong time. Many employees believe no action will be taken against the perpetrators [ 28 ], or they refuse to endure the stigmatization and the inconvenience of filing reports and following through on legal proceedings [ 29 , 30 ]. They are typically concerned that if they speak up about what has occurred to them, they will be shamed or labeled incompetent with a lack of supervisory support [ 12 , 29 ]. Furthermore, the harassed healthcare workers are even more concerned that the offenders may inflict additional harassment, violence, or threats on them and their family members if reports are made [ 31 ].

Hence, it further implies the need for proper awareness and recognition followed by clearly defined control and prevention measures of workplace violence in healthcare settings to prevent the negative impact of workplace violence to both the healthcare staffs and services. These measures are also vital to ensure that all healthcare workers, especially the front liners, are well protected in a safe working environment so that health care services can be continued to run smoothly without any interruptions for the benefit of the community.

5. Collaborative efforts in prevention and management of workplace violence in healthcare settings

The detrimental effects, mainly the psychological impact of workplace violence on affected healthcare employees, are one of the most critical reasons it must be handled before it escalates to higher absenteeism rates or further affects healthcare workers' overall performance. It will have even more negative implications for the healthcare sector when staffing is already scarce, and patient loads continue to rise inexorably.

Nonetheless, there is still much room for improvement in workplace violence awareness and abilities. There is an essential need to have a strong collaborative effort, support, and commitment from top management and the workers to protect themselves. There is no single guideline that is suitable for all settings. Hence, the management of each healthcare setting needs to create or adapt and establish a practical, acceptable and sustainable workplace violence prevention program. It should be according to the needs of their respective environments, using the available guidelines or recommendations by WHO, ILO, DOSH, and evidence-based research.

In non-emergency settings, interventions to prevent violence against healthcare professionals focus on techniques to better manage aggressive patients and high-risk visitors while in emergency circumstances, interventions are more focused on assuring the physical security of healthcare facilities [ 6 ]. Among some of the prevention and control measures in the sequence of effectiveness include; (i) substitution by transferring a client or patient with a history of violent behaviour to a more suitable secure facility or area [ 13 ]; (ii) engineering control measures which include installing barrier protection, metal detectors and security alarm systems, allocating conducive patients or visitors areas and clear exit routes [ 1 , 13 ]; (iii) administrative and work place practise controls which include implementing workplace violence response and zero-tolerance policies [ 1 , 17 , 24 , 32 ], ability to resolve conflict situation [ 33 ], establishing mandatory timely reporting system [ 34 ], ensuring employees are not working alone [ 35 ], flowchart for assessing and response in emergency situations [ 1 , 35 ]; (iv) post-incident procedures and services that include trauma-crisis counselling, critical-incident stress debriefing and employee assistance programs [ 35 ]; (v) safety and health training in order to ensure that all staff members are aware of potential hazards and how to protect themselves and their co-workers through established policies and procedures [ 32 , 35 , 36 ].

Aside from that, international or regional professional organizations, councils, and associations play essential roles in supporting, participating in, as well as contributing to initiatives and mechanisms aimed at minimizing and eliminating the potential risks of workplace violence in healthcare settings [ 5 , [37] , [38] , [39] ]. It includes but is not limited to (i) actively advocating on the awareness and training for workplace violence; (ii) incorporating in their codes of practice, codes of ethics, and clauses concerning the unacceptance of any form of workplace violence; (iii) integrating accreditation procedures in healthcare institutions on the requirement of measures aimed at preventing workplace violence; (iv) establishing workplace violence surveillance by mandatory and guided data collection procedures on the incidents of violence in all healthcare settings; and (v) offering support for victims of workplace violence, specifically in the form of legal aid if necessary.

In addition, participation and contribution from community groups, non-governmental organizations (NGOs), as well as business corporations in terms of technical support and financial assistance, play an essential part in curbing and preventing workplace violence in the healthcare settings [ 5 , 35 , [37] , [38] , [39] ]. Among the initiatives and activities which are highlighted include (i) creating and maintaining a strong network of information and expertise in workplace violence; (ii) assisting in promoting awareness of the risks of workplace violence; (iii) participating in training and educational programs; (iv) assisting in the support structure for the prevention and management of workplace violence; as well as (v) incorporating and emphasizing the importance of good communication skills and coping mechanism among the healthcare workers.

Summary of the risk factors, effects as well as the collaborative efforts which are important in the control and prevention measures for workplace violence in healthcare settings are tabulated in Table 1 .

Summary of risk factors, effects and collaborative management of workplace violence in healthcare settings.

6. Conclusion

It is undeniable that workplace violence needs to be addressed more comprehensively, involving shared responsibilities from all levels. These include (i) government's legislations; (ii) healthcare management's dedication, firm support, assurance, and clearly defined policy, reporting procedures, and training; (iii) the healthcare workers' commitment to update their awareness and knowledge regarding workplace violence; and (iv) the provision of technical support and assistance from professional organizations, NGOs, and the community.

Sources of funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Ethical approval

No ethical approval is required for this review.

Not applicable as it is a review and does not involve any new data collection from healthcare workers.

Author contribution

Mei Ching Lim drafted the initial manuscript and was involved in the literature search. Mohammad Saffree Jeffree was responsible for conceptualizing the study, facilitating manuscript writing, and approving the final manuscript. Saihpudin @ Sahipudin Saupin, Nelbon Giloi, and Khamisah Awang Lukman contributed expert input in literature search and facilitated manuscript writing. All authors have seen and approved the final manuscript.

Registration of research studies

Not applicable as it is a review and does not involve any new data collection from healthcare workers .

Dr Mei Ching Lim.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Declaration of competing interest

The authors report no conflict of interest nor proprietary or commercial interest in any product mentioned or concept discussed in this article.

Acknowledgements

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Addressing Workplace Violence and Creating a Safer Workplace

While violence in the workplace can occur across many industries and professions, this issue disproportionately impacts the healthcare workforce. Healthcare workers are five times more likely to sustain a workplace violence injury than other professions. In 2018, 73% of all nonfatal workplace violence-related injuries involved healthcare workers. 1 Even with such a high reported prevalence, the incidence of workplace violence is likely even higher due to underreporting. 2 Workplace violence in healthcare settings has become an increasing problem in recent years, particularly during the COVID-19 pandemic, which presented unique challenges for both patients and providers.

The National Institute for Occupational Safety and Health (NIOSH) defines workplace violence as violent acts, including physical assaults and verbal threats, directed toward persons at work or on duty. 3 Acts of violence against healthcare workers can range from verbal abuse to violent physical assaults. Risk factors for workplace violence in healthcare settings can include (1) unpredictable behaviors of patients and families who are often under emotional stress, as well as (2) organizational and systemic factors such as high-stress work environments, staff shortages, lack of organizational policies and staff training, overcrowding, long wait times, inflexible visiting hours, and lack of information. 4

In addition to violence that healthcare workers may experience from patients, families, or visitors, horizontal violence is also prevalent in healthcare. Horizontal violence can be defined as hostile, aggressive, and harmful behaviors toward coworkers via attitudes, actions, words, or other behaviors such as bullying, incivility, or hazing. 13 While this can occur across all healthcare professions, nurses are especially impacted, with one study estimating that 22% to 44% of nurses experience bullying at some point in their professional careers. 14

Workplace violence can jeopardize the safety of patients and staff. To highlight the importance of addressing this problem, the Joint Commission released a sentinel event alert in 2018 calling attention to the prevalence of violence in the healthcare workplace. The alert noted contributing factors and suggested actions for mitigating violence. 5 The Joint Commission released new workplace violence prevention standards in 2022 to guide hospitals in defining workplace violence and implementing organization-wide strategies to address the issue. 6 Interventions at the systemic, organizational, and individual levels are crucial to prevent workplace violence and better understand incidents when they do occur.

Types of Workplace Violence

The traditional press most often covers workplace violence incidents that yield devastating results, such as gun violence or homicide in healthcare settings. However, it is important to understand that workplace violence can take many forms, ranging from commonplace occurrences of verbal abuse to more serious acts of physical violence. Most incidents of workplace violence are verbal in nature; however, other types of incidents can include assault, battery, stalking, and sexual harassment. 5

Perpetrators of workplace violence can vary, and violence can occur from patients toward healthcare staff or between coworkers. The most common type of violence in healthcare settings is violence from patients, families, or visitors toward healthcare staff. 7 According to a 2019 survey on healthcare crime, about 78% of aggravated assaults and 88% of all assaults that occurred in hospitals were from patients and families toward healthcare workers. 8 Horizontal violence that occurs between coworkers may include personal bullying, job-related bullying, and intimidation. 15 Factors that lead to bullying among staff may include lack of experience or role conflicts, work overload, and insufficient support from management. 14

In addition to varying by type and perpetrator, workplace violence can vary across care settings. For example, emergency departments and psychiatric units are more likely to experience workplace violence than other care settings. 5 While some units or departments may experience a higher incidence of violence than others, workplace violence can impact all healthcare settings and is not limited to one particular area of care.

Trends and Impact

Workplace violence is not a new problem in healthcare. However, the incidence of violence has increased in recent years, particularly during the COVID-19 pandemic. According to the International Association for Healthcare Security and Safety’s 2019 Healthcare Crime Survey, physical assault against healthcare workers in hospitals increased from 7.8 incidents per 100 beds in 2014 to 11.7 incidents per 100 beds in 2018. 8 One study found that violent incidents in emergency departments rose from 1.13 incidents per 1,000 visits in the 3 months preceding the pandemic to 2.53 incidents per 1000 visits during the pandemic. 9 Another study conducted in Italy found that the monthly average of attacks against hospital workers increased from 13.5 events per 1,000 emergency department accesses per month in the pre-COVID-19 era to 27.2 in the pandemic months. 10 This rise in violence during the pandemic has been attributed to increased stress, anxiety, and isolation for patients and providers, as well as ongoing staffing issues and burnout. 9

While it is evident that workplace violence is an ongoing problem, it is also widely underreported. One study conducted at the University of Michigan estimated that the incidence of workplace violence could be up to three times higher than reported rates due to underreporting. 2 Another survey found that over the course of a year, 39% of healthcare workers experienced violence from patients and families (including physical assaults, physical threats, and verbal abuse), but only 19% of events were reported. 12

Underreporting of workplace violence incidents makes it difficult to estimate its true scope and impact. However, it is clear that workplace violence has broad-reaching and long-lasting implications for the healthcare workforce and subsequent effects on patient safety. Exposure to, or fear of, violence in the workplace can lead to negative psychological consequences for healthcare workers such as anxiety, depression, loss of self-esteem, and post-traumatic stress disorder. 4 Horizontal violence among staff can also have negative psychological consequences, such reduced self-esteem and increased risk for stress, anxiety, and depression. 15 These psychological effects can lead to higher rates of absenteeism and burnout , which can have negative downstream effects on quality of care and patient safety. 11 Workforce stress and burnout negatively impact patient safety culture , leading to consequent safety issues including increased errors and potential patient harm.

In addition to implications for patients and healthcare workers, workplace violence of all types negatively impacts healthcare organizations as a whole. Workplace violence is a leading cause of job dissatisfaction among providers, particularly nurses. Annual nurse turnover rates due to workplace violence are estimated to be between 15% and 36%. 11 Workplace violence incidents can lead to increased costs due to staff turnover, costs for treating injuries, and staff time away from work. 11

Strategies to Address Workplace Violence

To effectively address workplace violence to create a safer healthcare environment for patients, families, and providers, it is imperative to implement interventions at both the organizational and individual levels. When reviewing the effectiveness of violence prevention training for nurses, research has found that these trainings lead to increased confidence and improved communication skills. However, the trainings are ineffective as standalone methods to reduce workplace violence without additional organizational interventions. 11

At the organizational level, leaders should take steps to address barriers to reporting workplace violence incidents in order to better understand, address, and prevent problems. Underreporting of workplace violence incidents may be due to healthcare workers’ beliefs that violence is an expected part of the job, beliefs that no action will be taken against perpetrators of violence, fear of negative consequences from reporting, or a lack of easily accessible reporting systems. 3 Implementation of straightforward and easy-to-use reporting systems combined with support and action from leaders can help address these barriers, reduce the burden of reporting for healthcare staff, and prevent further burnout. 7

The Joint Commission recommends that, in addition to addressing barriers to reporting, healthcare leaders should make it clear that it is the organization, rather than the victims of violence, that is responsible for addressing workplace violence. At the organizational level, leaders should cultivate safer work environments by developing clear workplace violence protocols and taking steps to address issues such as staffing shortages and turnover. 5 The Joint Commission also recommends that healthcare organizations capture and track workplace violence incidences from all available sources, including databases used for insurance, security, human resources, and employee surveys, and use this data to inform quality improvement initiatives to reduce incidences of workplace violence. 5 These initiatives may involve changes to the physical work environment, such as enhanced security and better exit routes, as well as changes to work practices or administrative procedures, such as developing workplace violence response teams and providing adequate mental health support on-site. 5

Effective January 2022, the Joint Commission released new and revised standards for the prevention of workplace violence in hospitals. These standards require that hospitals manage safety and security risks by establishing processes for continually monitoring, reporting, and investigating incidents related to workplace violence. They also require that staff participate in ongoing education and training, and that leaders create and maintain a culture of safety and quality throughout the hospital. 6

Creating a culture of safety within organizations is also crucial to addressing horizontal violence and bullying in the healthcare workplace. It is critical for organizations to establish and enforce a zero-tolerance policy towards bullying, as tolerance of bullying at the organizational level is closely related to bullying prevalence. 16 By implementing anti-bullying interventions, such as manager training, teambuilding exercises, and clear reporting systems, organizations can enhance allyship, communication, empowerment, and trust among healthcare staff, thus creating a safer work environment for patients and staff alike. 16

Looking Forward

Workplace violence is a complex issue that affects more than the workers who experience it. Safety leaders recognize workplace violence as a significant patient safety issue; workforce safety is one of four foundational areas in the National Action Plan to Advance Patient Safety . This document, which is focused on improving patient safety at the national level, was created by the National Steering Committee for Patient Safety, an interdisciplinary workgroup of leading healthcare organizations, associations, patient and family advocates, and federal agencies, including AHRQ.

To achieve improved workforce safety, organizations should start with a systems approach, which includes a comprehensive safety program overseen by senior leaders and clinical leader oversight for accountability for physical and psychological safety at the clinical and unit level. Development of programs to prevent and address workplace violence should be complemented by programs that support psychological safety and joy at work. The Implementation Resource Guide of the National Action Plan provides specific tactics and resources that organizations can use as they assess the status of their current initiatives to address workplace violence and develop programs to prevent violence and create safer spaces. By establishing policies and procedures to prevent and address workplace violence incidents on multiple levels, healthcare organizations can take steps toward creating a safer environment for both patients and providers.

• U.S. Bureau of Labor Statistics. Workplace Violence in healthcare, 2018 . Accessed August 23, 2023. https://www.bls.gov/iif/factsheets/workplace-violence-healthcare-2018.htm
• Rosenman KD, Kalush A, Reilly MJ, Gardiner JC, Reeves M, Luo, Z. How much work-related injury and illness is missed by the current national surveillance system? J Occup Environ Med . 2006;48(4):357-365.
• The National Institute for Occupational Safety and Health (NIOSH). Violence: Occupational Hazards in Hospitals . Centers for Disease Control and Prevention; 2002. Accessed October 3, 2023. https://www.cdc.gov/niosh/docs/2002-101/default.html#print
• Lim MC, Jeffree MS, Saupin SS, Giloi N, Lukman KA. Workplace violence in healthcare settings: the risk factors, implications and collaborative preventive measures. Ann Med Surg . 2022;78(78):103727. doi: https://doi.org/10.1016/j.amsu.2022.103727
• The Joint Commission. Physical and Verbal Violence Against Health Care Workers . Issue 59. Sentinel Event Alert. 2018. Accessed August 23, 2023. https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/sea-59-workplace-violence-final2.pdf
• The Joint Commission. Workplace Violence Prevention Standards . R3 Report: Requirement, Rationale, Reference. 2021. Accessed August 23, 2023. https://www.jointcommission.org/-/media/tjc/documents/standards/r3-reports/wpvp-r3_20210618.pdf
• Kim S, Lynn MR, Baernholdt M, et al. How does workplace violence-reporting culture affect Workplace violence, nurse burnout, and patient safety? J Nurs Care Qual . 2023;38(1):11-18. 10.1097/ncq.0000000000000641
• Vellani KH. The 2019 IAHSSF Healthcare Crime Survey . IAHSS Foundation; 2019. Accessed October 3, 2023. https://iahssf.org/assets/2019-Healthcare-Crime-Survey-IAHSS-Foundation.pdf
• McGuire SS, Gazley B, Majerus AC, Mullan AF, Clements CM. Impact of the COVID-19 pandemic on workplace violence at an academic emergency department. Am J Emerg Med . Published online September 2021. doi: https://doi.org/10.1016/j.ajem.2021.09.045
• Brigo F, Zaboli A, Rella E, et al. The impact of COVID-19 pandemic on temporal trends of workplace violence against healthcare workers in the emergency department. Health Policy . 2022;126(11):1110-1116. doi: https://doi.org/10.1016/j.healthpol.2022.09.010
• Somani R, Muntaner C, Hillan E, Velonis AJ, Smith P. A systematic review: effectiveness of interventions to de-escalate workplace violence against nurses in healthcare settings. Saf Health Work . 2021;12(3):289-295. doi: https://doi.org/10.1016/j.shaw.2021.04.004
• Pompeii LA, Schoenfisch AL, Lipscomb HJ, Dement JM, Smith CD, Upadhyaya M. Physical assault, physical threat, and verbal abuse perpetrated against hospital workers by patients or visitors in six U.S. hospitals.  Am J Ind Med . 2015;58(11):1194-1204. doi:10.1002/ajim.22489
• Jaber H, Abu M, Mahmoud Al Kalaldeh, et al. Perceived Relationship Between Horizontal Violence and Patient Safety Culture Among Nurses. Risk Management and Healthcare Policy. 2023;Volume 16:1545-1553. doi: https://doi.org/10.2147/rmhp.s419309
• ‌ Shen Hsiao ST, Ma SC, Guo SL, et al. The role of workplace bullying in the relationship between occupational burnout and turnover intentions of clinical nurses. Applied Nursing Research. Published online August 2021:151483. doi: https://doi.org/10.1016/j.apnr.2021.151483
• Kim Y, Lee E, Lee H. Association between workplace bullying and burnout, professional quality of life, and turnover intention among clinical nurses. Heslop L, ed. PLOS ONE. 2019;14(12):e0226506. doi: https://doi.org/10.1371/journal.pone.0226506
• Jang SJ, Son Y, Lee H. Intervention types and their effects on workplace bullying among nurses: A systematic review. Journal of Nursing Management. 2022;30(6). doi: https://doi.org/10.1111/jonm.13655

In Conversation with... Cheryl Jones about Addressing Workplace Violence and Creating a Safer Workplace

Editor’s note: Cheryl B. Jones is a professor, director of the Hillman Scholars Program, and interim associate dean of the School of Nursing’s PhD program at the University of North Carolina at Chapel Hill. We spoke to her about workplace violence trends in healthcare settings and how we can create a safer work environment for healthcare staff.

Sarah Mossburg: Can you tell us about yourself and your current role?

Cheryl B. Jones: I am a Professor at the University of North Carolina Chapel Hill , and currently I serve as interim associate dean for our PhD program and PhD/post-doctoral programs. I’m also the Director of the Hillman Scholars Program , a BSN through PhD pathway for nurses to be prepared as nurse scientists.

Sarah Mossburg: Can you describe, at a high level, the focus of your research and its intersection with workplace violence?

Cheryl B. Jones: I’ve been studying the healthcare workforce for over 30 years. I began by looking at the cost of nurse turnover, and later I examined the relationship between turnover and the work environment. I have also studied other aspects of the work environment, like staffing, and more recently, workplace violence with my colleague, Dr. Sinhye Kim, with whom I’ve coauthored three papers. My work largely focuses on the organization, delivery, and financing of care, and how the healthcare system and the workforce affect care delivered to patients and their families. I focus on how we can improve the work environment for staff, and, in turn, the care for patients and families.

Sarah Mossburg: What types of violence are healthcare workers experiencing? For example, patient/family to workers, staff to staff? And what forms of violence are we seeing: Is it physical, verbal, something else?

Cheryl B. Jones: Violence can take any of the forms you mentioned. There is certainly violence from patient and family toward staff, but also bullying and other negative behaviors occur between staff, both among the same kinds of professionals and across professional groups. When you’re working in an organization where there are clear power differentials and stressful conditions, there’s always potential for some level of tension, some of which may lead to violence.

Workplace violence has always been present in healthcare. We’ve seen increased reporting coming out of the pandemic, especially violence from patients and families toward healthcare providers. Workplace violence can take a broad spectrum of forms, from verbal abuse to mild and more violent physical acts against healthcare workers. Based on findings from our team’s research, there’s a greater potential for verbal violence, and there is increasing fear about acts of physical violence targeting healthcare providers. 1 We’ve seen recently in the press that shootings have occurred in healthcare organizations, with patients or family members targeting healthcare providers, so workplace violence can have devastating effects.

Sarah Mossburg: You mentioned increased reports of violence during the pandemic. Do you think that the incidence of violence is increasing, or are we just shining a spotlight on it?

Cheryl B. Jones: I think it could be a little of both. In social media and the traditional press, we have seen the public reporting of specific violent events that have occurred. In some cases, it’s hard to discern if the reporting is true, if the incidence of workplace violence has really increased, or if better reporting is shining the spotlight on it. Regardless, this important organizational and patient safety concern deserves focused attention.

Sarah Mossburg: Are there certain types of workplace violence that are more common?

Cheryl B. Jones: We hear more about the verbal and physical violence from patients and families directed toward healthcare workers today. We’re also seeing more about bullying among staff in the workplace. Our findings indicated that verbal violence from patients (e.g., insults, threats, screaming, cursing) occurs most frequently, followed by verbal violence from visitors (including family members) and physical violence from patients (e.g., hitting, grabbing, biting, scratching).

Not always “framed” as violence, bullying may involve some behaviors, such as micro-aggressions, that could be considered violence-like behaviors, especially verbal bullying. I think the most concerning, at least in the immediate sense, is the violence that occurs from patients and family toward healthcare providers because the exposure of clinicians to patients is broad and sometimes longer-term. Also, providers are vulnerable if they lack information about high-risk situations, the processes and systems available to help address them, and the resources needed to respond to an act of violence that may be aimed at them.

Sarah Mossburg: Are there certain settings that have higher incidence of workplace violence?

Cheryl B. Jones: Hospitals are a common setting because they admit large numbers of patients and employ large numbers of healthcare professionals, with opportunities for workplace violence events to occur. Although we think that certain units may have a patient population that may predispose workplace violence to occur, the reality is that we see workplace violence across all types of units, even perinatal care. Opportunities for workplace violence occur in long-term care facilities because of their patient population and the types of care they deliver.

Sarah Mossburg: What are some of the challenges in understanding workplace violence?

Cheryl B. Jones: I think that challenges on multiple levels—societal, systemic, and organizational—give rise to violence. It’s not as simple as one level versus another, but rather it’s a multilevel problem. There are even challenges at a unit level, to some degree, where staff working on certain units within hospitals are more familiar with exposure to violence arising from patients or family members. Patients admitted to the emergency department with problems may predispose them to exhibit aggressive behaviors, or the unit may be short-staffed, or care provided on the unit may be delayed. These and other factors in the emergency department environment could elicit violent behaviors.

At the organizational level, systems may be lacking for staff to safely report incidents of violence, which makes it hard to understand the real magnitude of the problem. There are also issues with staffing. Nurse staffing has been a great challenge to address coming out of the pandemic. If patients and families don’t feel they are receiving proper care or if there are not sufficient staff to care for their loved ones, then they may be more likely to act out violently in some way.

Also, I think it’s important to acknowledge challenges at the societal level. In recent years, in addition to workplace violence events that may occur in healthcare organizations, many violent incidents have been reported across the country. These events threaten the safety of all of us. Patients and families assume that healthcare providers and organizations are safe places—they actually treat victims of physical and psychological violence. But b ecause violence is occurring across the country and workplace violence is occurring in healthcare organizations, patients and families may be hesitant to seek care for fear of being exposed to violence. There should be a consensus at the societal and policy levels that healthcare providers are safe environments for everyone who seeks care.

Sarah Mossburg: You mentioned the potential for underreporting due to the lack of available reporting systems. Are there other factors that may contribute to underreporting?

Cheryl B. Jones: I think there are a few things. For example, some reporting systems that we do have are complicated, difficult to use, or not easily accessible. Clinicians are busy, and it’s hard for them to find time to report, especially if that means taking time away from their patients. It is also one more thing for health professionals to do or to remember to do when they are already stretched. There is fear among healthcare clinicians of potential retribution from reporting. Staff could fear that reporting might negatively affect them, put their jobs at risk, or be shared with family members of, say, a patient exhibiting violent behaviors who could hold it against the clinician.

Staff may also believe that nothing will change or improve, even if they put time and effort into reporting incidents, and this belief discourages them from reporting. The absence or lack of system-level supports after an incident has been reported is also a factor contributing to under-reporting.

There are a number of challenges with reporting and making it easier for clinicians to report acts of violence when they occur. There is interest in electronic apps that would allow patients, families, and staff to report acts of violence more easily, but these solutions are not widely available at this time.

Sarah Mossburg: Do you think healthcare staff may see workplace violence as status quo? Meaning, do you think that staff are so accustomed to workplace violence that the line between verbal incivility and verbal violence is blurred, making it difficult for staff to recognize violence?

Cheryl B. Jones: Let’s face it: Workplace violence is often tolerated by clinicians because they see it as a part of the job. A lot of violence, especially verbal, goes unrecognized or dismissed because clinicians expect it, and therefore they tolerate it on some level until it escalates.

Sarah Mossburg: What kinds of long-lasting impacts do you see on the workforce and individuals related to workplace violence?

Cheryl B. Jones: In some of the work I’ve done with Dr. Kim and other colleagues , we’ve reported a connection between workplace violence and burnout. We know that burnout can lead to an increase in sick time or missed time from work and, ultimately, staff departures from organizations. Right now, there is a shortage of healthcare workers, particularly in certain segments of the workforce, such as nurses. When violence is layered on top of an already stressful work environment, it could potentially escalate problems with burnout, turnover, and staffing shortages.

Sarah Mossburg: How do you think workplace violence impacts patient safety?

Cheryl B. Jones: When workplace violence occurs, it can spill over and make others—patients, visitors, and staff—fearful about what might happen to them. Patients may worry about what could happen to them during their stay, and the uncertainty and at times abrupt occurrences of violence can make both patients and staff feel helpless or psychologically unsafe. The experience of a violent event can linger with a person for a long period of time. The person or persons who experience the event may feel the psychological effects into the future. Nurses, physicians, and other clinicians exposed to violence may experience burnout. With or without burnout, the disturbance of the event could change structures and processes in ways that both disrupt workflows and cause errors in care. Workplace violence can disrupt the patient safety culture and limit leaders’ ability to create a safe patient environment. It can also cause patients, families, and clinicians to worry about their safety in the healthcare environment and erode trust in the organization and system.

Sarah Mossburg: What are some things we should think about at the organizational and systemic levels to reduce workplace violence?

Cheryl B. Jones: I think when addressing the problem of workplace violence, focusing on a provider or organizational level is only one piece of the puzzle. It really is a multilayered problem that starts with policymakers, payers, and providers, including healthcare organizations.

Organizations can create a better work environment that supports better care by addressing the organizational concerns that give rise to unhappy patients, including increasing staffing, addressing clinician burnout, and creating a safety culture for both patients and clinicians. When the healthcare workforce is tired, burned out, and stressed out, it’s really important to address those issues so that the environment for care delivery is safe on a basic level.

Organizations can also think carefully about the organizational actions needed, including evidence from the literature, the Joint Commission, the National Academy of Medicine, and other national groups. 2 A broad organizational approach should include technologies that are needed to address challenges related to the reporting of workplace violence events and the collection of workplace violence event data. These technologies could be available to staff—and to patients and families—to engage those in the environment to report an event.

We hear a lot about de-escalation techniques, and I think those are important when it becomes apparent that a situation is going awry. But in some cases, these techniques are not enough. You probably heard about the recent incident in Oregon, where a security guard suffered a fatal injury from a patient’s family member. At some point, it’s almost too late for de-escalation when a situation reaches the point of reporting. Verbal violence may be a first indicator of potential physical violence, so it’s important to be attuned to those acts when they occur, to take steps toward prevention of a workplace violence event, and to be vigilant about reporting. Reporting systems must be safe, convenient, and not overburdensome for staff. We must also educate workers at all levels to understand workplace violence, to know when and how to take appropriate actions, and to follow accepted organizational procedures and professional standards.

Sarah Mossburg: It sounds like you’re advocating for addressing some of the root causes of an unsafe work environment that may contribute to workplace violence. Organizations should be thinking about staffing, policies around reporting, monitoring, and being alert to the signals they’re seeing in those reports, so that they can identify early indicators of a rise in violence.

Cheryl B. Jones: Absolutely. We know that violence is occurring, so organizations have to be diligent, and situational awareness within an organization is important. Some requirements today, such as those from the Joint Commission, 3 require organizations to be more diligent and have systems and processes in place to protect patients and staff. Basic patient safety activities, which include promoting teamwork, good handoffs, timely responses to patients and families, appropriate sharing of information, and good transitions in care, help build a culture of patient safety. We know that a good patient safety culture is a culture where people feel psychologically safe working, where they can speak up when things are going wrong, and where they want to work.

Sarah Mossburg: What do you see as some of the greatest opportunities for improvement, as it relates to workplace violence?

Cheryl B. Jones: I think there are several opportunities to improve current approaches to addressing workplace violence, such as implementing safer, more convenient, and more user-friendly reporting systems. There is also an opportunity to help organizational leaders and managers improve responses to, and management of, workplace violence events. A recent Health Affairs blog outlined some of these opportunities, 3 and steps have been outlined from other professional and regulatory groups. Management and leadership support can really make a difference. When staff feel psychologically safe, feel heard by their managers and leaders, and believe managers and leaders will act on reported information, they are more likely to report workplace violence when it occurs.

Sarah Mossburg: What reporting methods or strategies would you recommend that organizations use to better understand how, where, and why workplace violence occurs?

Cheryl B. Jones: We should think about how we can leverage technology to address workplace violence and make it easier for clinicians and others to report. The systems that we’ve had in the past are complicated, time consuming, and often onerous to use. Having reporting systems in place that facilitate the reporting of events when they actually occur is important.

Sarah Mossburg: We’ve talked a lot about the big picture of addressing workplace violence at the organizational level. What are some ways on a day-to-day basis that frontline healthcare workers can address the violence that they’re seeing and experiencing?

Cheryl B. Jones: Certainly, if they’re trained on organizational procedures and policies to address workplace violence when it occurs, and in de-escalation techniques, that will be important. I think it’s easy to point to steps that workers can take, but addressing workplace violence is a systemic problem. It’s important that staff know what to do if a situation escalates and what resources are available to them, but that’s only a very small piece of the puzzle. Staff training is important, but organizational supports are critical.

When you look at the statistics, healthcare workers are four to five times more likely to be exposed to workplace violence than any other industry. 4 They operate in high-stress and often unstable environments that can put them in situations that expose them to violence. 5 We need to make workers feel safe and put resources at their fingertips.

You have to think about the people we serve in healthcare. They come in when they themselves or their family members are at their most vulnerable. If the healthcare work environment doesn’t support the delivery of care, and patients and families don’t feel that they and their loved ones are getting the care that they need, I think we can, on some level, understand why they might feel dissatisfied with care and lash out. But if the environment that exists doesn’t give rise to those feelings of dissatisfaction to start with, then there we might see workplace violence decline.

Sarah Mossburg: What you just said makes me think that people are almost in a fight or flight response because they’re just so overwhelmed in some situations. I agree with your point that you can understand, to some extent, where some of that violence comes from.

Cheryl B. Jones: I do understand where patients’ and families’ anger or concern may come from; but I don’t truly understand where the violence comes from. However, the feelings of vulnerability in a system about your health and safety and that of your loved ones, or feelings that care is not delivered safely, could create a sense of urgency that pushes people over the edge at times.

Sarah Mossburg: You seemed to be making the point that we have to be careful not to rely solely on how healthcare workers can fix violence in the moment just because they happen to be the ones experiencing it. That seems to align with the way we often think about patient safety: just because a healthcare worker was at the blunt end of an error, doesn’t mean that they were the cause of that error, and should be able to stop it from occurring next time. Do you agree with that framing?

Cheryl B. Jones: I absolutely agree. Patient safety approaches generally emphasize a “systems” approach to create safe work environments; thinking about workplace violence similarly could help address the root causes of workplace violence. If we give healthcare workers the tools and techniques to deal with workplace violence, as we do with patient safety—such as creating a patient-centered environment, examining the root causes of workplace violence, debriefing with staff when a workplace violence event occur, and creating response teams to address workplace violence events in the moment—then we could move toward creating an environment that is safer for patients, families, and staff. We know that there’s a connection between patient safety culture and healthcare workers feeling like they’re in an environment where they can practice safely. If we viewed workplace violence as part of that patient safety culture, then workers and patients may feel safer when they enter the healthcare setting and receive care.

Sarah Mossburg: You mentioned de-escalation techniques earlier. Are those effective, and are they being used?

Cheryl B. Jones: A lot of training around de-escalation is occurring across the country in hospitals and various healthcare settings. I think de-escalation techniques are necessary but are not sufficient. You need other areas of support, like leadership support, access to security staff, and supportive technologies because de-escalation can help, but it is unlikely to solve the problem entirely. It’s a matter of having a system in place so that resources are available and easily accessible for staff when needed. It gets back to having a safe environment with resources in place in a way that individuals can access the resources, report an event when it happens, and quickly get help when they need it.

Sarah Mossburg: You just mentioned access to security. I’ve seen in the news and heard from colleagues that health systems are increasing security in response to the rise in incidents of workplace violence. Is that correct, and what are your thoughts about that?

Cheryl B. Jones: Yes, I’m reading and hearing about it in the press and on the news as you are. I’ve seen there are systems creating and deploying their own police forces. I think it’s a sad state that we’re here. Patients and families are at their most vulnerable when they come to receive healthcare. They come to us because they want or need our help. When the conditions are such that they don’t get the help they need, don’t get it fast enough, have to wait long periods of time with no response from providers, or come into the emergency department but are sent home only to bounce back again, it creates an environment where people stop trusting the system. It’s a larger, systemic problem, it’s an organizational problem, and then it’s really a problem of public policy.

Sarah Mossburg: You’ve mentioned policy makers as one of the potential shareholders involved in addressing workplace violence. Do you have thoughts about what that might look like?

Cheryl B. Jones: There are different types of policy, including public policy, system policies (like the Joint Commission and other groups), and organizational policies. I think you really need policies at all those levels.

I think on a public policy level, legislation is needed to support and incentivize organizations to report workplace violence more accurately. Congress has introduced a bill called the Workplace Violence Prevention for Health Care and Social Service Workers Act, which has passed the house and is now in the Senate. We need our legislators to take action to protect patients and healthcare workers when they are in healthcare settings.

In healthcare, policies have been created that require organizations to report patient outcomes, including satisfaction with care. P atient satisfaction is an element of healthcare reimbursement. What can happen is that organizations may fear having any reports released that indicates their system may have experienced a workplace violence incident. On a public policy level, attention should be given to supporting systems and organizations in more accurately reporting workplace violence, such as incentivizing them to use reporting systems and technolog ies that enable tracking of events. Thus, interventions are needed—through legislation and industry-wide changes—to address workplace violence. 

Sarah Mossburg: What are some areas for future research in this field?

Cheryl B. Jones: We need to look at how clinicians, nurses, physicians, and others who experience workplace violence are affected. We’ve talked about how similar workplace violence is to quality and patient safety concerns. Research to develop, pilot, implement, evaluate, and modify interventions to address workplace violence, along with the measurement of workplace violence, are areas ripe for study. We can look to theories that come from within and outside of healthcare, including health services research approaches, organizational theory, and organizational psychology, as guides for the theoretical and conceptual framing of research.

We also need to look at the effectiveness of strategies such as technologies, de-escalation techniques, and programs to address workplace safety. We should examine the effectiveness as well as the cost and return on investment of implementing these kinds of programs. Because research on workplace violence is emerging, we need to focus on both the substantive areas associated with workplace violence, as well as the methodological areas to build the science and contribute to generalizable knowledge.

Sarah Mossburg: Are you aware of any promising research exploring ways to prevent workplace violence from occurring?

Cheryl B. Jones: The research emerging from local facilities and systems around the use of technologies, applications, and artificial intelligence (AI) for reporting are intriguing. For example, studies are underway examining the use of apps that allow clinicians and patients to report workplace violence. I’m sure there are potential AI uses and implications for workplace violence and patient safety that we’re not adequately utilizing at this point. The world around technology and the use of AI is ripe for future research.

This focus goes hand in hand with some of the policy work that could be directed at addressing workplace violence, based on research supported through the Agency for Healthcare Research and Quality (AHRQ), the National Institutes of Health (NIH), and private foundations. These efforts are critical. These groups support the implementation of local quality improvement initiatives that could focus on workplace violence.

Sarah Mossburg: Are there any new improvements that have been shown to be impactful on mitigating workplace violence?

Cheryl B. Jones: Organizations now have workplace violence or workplace safety committees, so I think those kinds of things should definitely be supported. We can use strategies we know work in patient safety and quality—such as root-cause analysis, rapid response teams, and event debriefing—to understand what happened during incidents of workplace violence, identify what processes and policies need to change, and determine what levers need to be pulled at the practice level to support quality improvement, and at the policy level to bring about meaningful changes in organizations.

I mentioned management and leadership support earlier. We know that in patient safety, safety champions are needed to support patient safety initiatives. Similarly, we need leaders to champion initiatives that address worker safety, protect and support staff when incidents happen, and ultimately protect patients.

Sarah Mossburg: That’s a great suggestion. It was interesting to hear you talk about workplace safety committees as well. Before we close, is there anything that I didn’t ask you that you think would be important to talk about?

Cheryl B. Jones: I’d like to reinforce the links among workplace violence, the work environment, and the quality and safety of patient care. We know that conditions in the work environment can lead to clinician burnout, feelings of being psychologically unsafe, and potentially to organizational turnover and departures from healthcare organizations and perhaps even the profession. We’re in the midst of a healthcare workforce shortage. If we’re serious about keeping our workforce healthy and in place, we must pay attention to workplace violence. It is one of those things that can tip people over in their decision to leave a unit, leave an organization, and maybe even to leave the workforce. At a time when we critically need healthcare workers, we need to appreciate the importance of addressing the work environment, including workplace violence.

The nature of violence is different in different situations. It can arise from patients and families, as well as among healthcare workers. We need to understand more about the workers themselves and what happens in the work environment, and we need to engage patients and families to understand and address what gives rise to violence, and how workplace violence affects patients and families. We need to understand all angles to identify strategies that address the antecedents, processes, and consequences of workplace violence.

Sarah Mossburg: That was such a perfect call to action for us to end on. Thank you so much for talking to us today.

References :

• Kim S, Kitzmiller R, Baernholdt M, Lynn MR, Jones CB. Patient safety culture: the impact on workplace violence and health worker burnout. Workplace Health Saf . 2023;71(2):78-88. doi:10.1177/21650799221126364
• Beeber L, Delaney KR, Hauenstein E, Iennaco J, Schimmels J, Sharp D, Shattell M. Five urgent steps to address violence against nurses in the workplace. Health Affairs Forefront , August 23, 2023. 10.1377/forefront.20230822.174151. Accessed September 25, 2023. https://www.healthaffairs.org/content/forefront/five-urgent-steps-address-violence-against-nurses-workplace
• Arbury S, Zankowski D, Lipscomb J, Hodgson M. Workplace violence training programs for health care workers: an analysis of program elements.  Workplace Health Saf . 2017;65(6):266-272. doi:10.1177/2165079916671534
• U.S. Bureau of Labor Statistics. Workplace violence in healthcare, 2018. Accessed August 23, 2023. https://www.bls.gov/iif/factsheets/workplace-violence-healthcare-2018.htm
• U.S. Department of Labor. Workplace violence in healthcare: understanding the challenge. Accessed September 25, 2023. https://www.osha.gov/sites/default/files/OSHA3826.pdf

This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers

Annual Perspective

Perspective

Perspectives on Safety

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A natural language processing approach to categorise contributing factors from patient safety event reports. August 30, 2023

Healthcare 411: medication safety toolkit. March 18, 2009

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Patient Safety Primers

Discharge Planning and Transitions of Care

Medicines-related harm in the elderly post-hospital discharge. March 27, 2019

Guide to Reducing Unintended Consequences of Electronic Health Records. October 5, 2011

Implementing a Program of Patient Safety in Small Rural Hospitals. January 16, 2008

Trust and Safety. November 8, 2006

Parkland knee surgery done by doctor in training leads to amputation, questions. December 1, 2010

First, protect the patient from harm: applying adult learning principles to patient safety. August 18, 2010

Medication mix-ups. March 17, 2010

ECRI out with 10 deadly healthcare technology hazards for 2017. November 23, 2016

Lessons from America's safest hospitals. April 17, 2013

Doctors make mistakes. Can we talk about that? February 8, 2012

Minor mistakes, deadly results. February 8, 2012

Review into the Quality of Care and Treatment Provided by 14 Hospital Trusts in England: Overview Report. August 7, 2013

Medical errors leave devastating impact on families, professionals. May 15, 2013

Is a tired doctor a safe doctor? November 12, 2014

Doctor uses 'pre-flight' checklist. May 3, 2006

External Inquiry into the adverse incident that occurred at Queen's Medical Centre, Nottingham, 4th January 2001. April 26, 2006

Alleged kidnapper agrees to extradition. March 28, 2007

Hospital safety records, CEO pay increasingly linked. December 5, 2007

Talking pill bottle aims to curb medical errors. August 17, 2005

Not what the doctor ordered. July 13, 2005

Patient Safety Handbook, Second Edition. August 17, 2013

Rapid response teams improve outcomes—Part 1, Part 2, and Part 3. March 30, 2016

Hospitals leery of reporting serious errors. March 16, 2011

Human costs of training doctors. August 11, 2010

A girl dies during restraint at hospital already criticized for problems. August 11, 2010

Discharge missteps can send seniors back to hospital. March 3, 2010

Wounded care: failure at one Indian Health Service hospital reveals a system in crisis. December 14, 2016

The Habits of an Improver. Thinking About Learning for Improvement in Health Care. December 16, 2015

Thousands of doctors practicing despite errors, misconduct. August 28, 2013

Doctors perform thousands of unnecessary surgeries. July 10, 2013

High Reliability for a Highly Unreliable World: Preparing for Code Blue Through Daily Operations in Healthcare. May 16, 2018

Patient safety culture in nephrology nurse practice settings: initial findings. December 3, 2014

Patient Safety in Private Hospitals: the Known and the Unknown Risk. September 10, 2014

Health Care Errors and Patient Safety. May 13, 2009

Indiana Medical Error Reporting System Final Reports. September 10, 2008

Error reporting in organizations. October 18, 2006

Learning from Disasters: A Management Approach. Third ed. July 12, 2006

Rapid response teams and continuous quality improvement. November 25, 2009

Examining medication reconciliation from a perspective of safety. September 25, 2013

Patient-safety and quality initiatives in the intensive-care unit. April 5, 2006

The National Medical Error Disclosure and Compensation (MEDiC) Act. October 12, 2005

Feeling safe in the context of digitalization in healthcare: a scoping review. April 10, 2024

Patient Safety Innovations

Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes)

A proposed approach to allegations of sexual boundary violation in health care. December 13, 2023

Authentic leadership at the Cleveland Clinic: psychological safety in the midst of crisis. November 15, 2023

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

'Speaking Up' for patient safety and staff well-being: a qualitative study. June 7, 2023

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Medical errors kill thousands of people each year. But are hospitals getting any safer? May 17, 2023

Laura Levis' death outside ER has changed hospital signage, lighting in Mass. May 10, 2023

Deficiencies in Emergent and Outpatient Care of a Patient with Alcohol Use Disorder at the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana. April 19, 2023

Listening, Learning, Responding to Concerns. April 12, 2023

A decade after Francis: is the NHS safer and more open? April 5, 2023

CHaMP: A model for building a center to support health care worker well-being after experiencing an adverse event. April 5, 2023

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Workplace Violence in Healthcare: Causes, Regulations, and Prevention Strategies

Workplace violence between patients and caregivers is a fundamental challenge in society. For example, healthcare providers often interact with unstable patients who could be under the influence of drugs, are gang members, or have a history of violence. Such aggressive patients might inflict physical and psychological harm to caregivers through threats, verbal abuse, harassment, and hostility. As a result, nurses are subjected to unnecessary stress, trauma, and injuries that impair their duties and responsibilities in a healthcare environment. According to the Bureau of Labor Statistics, workplace violence in hospitals is more common than in other industry sectors, which raises the need for intervention. Analyzing political, legal, and legislative factors that influence workplace violence and preventive measures and protocols in hospital settings would be essential in solving this serious problem.

The Political, Legal, and Legislative Factors that Influence Violence in Healthcare Setting

Various risk factors facilitate violence in health care. Patients are the main initiators of workplace violence in a healthcare environment; however, political, legal, and legislative factors also contribute to the problem. Thus, political factors include the understaffing of nurses, which implies that the government has failed to employ adequate personnel to deal with the increasing population and reduced the number of older nurses who retire. As a result, the ratio of healthcare providers is low, which reduces efficiency in caring for patients who often become agitated, resulting in violence. Another political factor is inadequate healthcare resources, whereby the government fails to distribute adequate resources for healthcare. As such, such a situation fosters poor quality of care and patients’ negative attitudes toward healthcare providers. The insufficient allocation of funds is another political factor influencing healthcare violence. The government does not provide enough funds for hospitals to invest in security.

At the same time, the legal and legislative factors that foster violence in the healthcare environment consist of the Affordable Care Act, which has enabled wide access to healthcare services via government-subsidized insurance coverage. As a result, healthcare centers have been overwhelmed, which leads to long waiting hours and often causes patient dissatisfaction and workplace violence. Another legislative factor is the lack of signs in the hospitals, warning against workplace violence. Thus, patients, who could be under the influence of drugs, perceive violence as normal in healthcare. The lack of clear legislation to prevent and report workplace violence is another legal factor that encourages the problem, which causes most violent encounters between patients and care providers to go unreported. Thus, it is clear that various political, legal, and legislative factors influence workplace violence in healthcare.

Evaluation of OSHA Regulations and the ANA Position Statement on Workplace Violence to Organization Policies

The Occupation Safety and Health Association (OSHA) is committed to eradicating workplace violence. According to Papa and Venella, the OSHA regulations on workplace violence presuppose management commitment, employee participation, worksite analysis, hazard prevention and control, safety and health training, recordkeeping, and program evaluation. Thus, management commitment and employee participation regulations direct the organization’s managers and frontline employees to work together to promote the safety of health workers and their patients. The worksite analysis regulation prompts organization policies to assess a workplace for potential hazards that could cause violence by conducting a screening survey and analyzing the hospital’s security. Hazard prevention and control imply an organization’s policies that aim to design mitigation and control measures for hazards identified through the worksite analysis. The safety and health training regulation guides organizations to raise awareness among the staff about the workplace hazards present and teach them how to protect themselves. Lastly, recordkeeping and program evaluation enable an organization to evaluate the success and effectiveness of the programs established for sustainable, safe working conditions.

The American Nurses Association (ANA) is similarly committed to ending workplace violence in healthcare. The organization affirms that nurses are committed to helping others; however, they should also be treated with respect and dignity in the workplace. As Saltzberg and Clark claim, the ANA’s position statement on workplace violence in organizations’ policies includes zero tolerance towards this phenomenon among healthcare providers. Hence, physical and emotional abuse are no longer accepted as a part of nurses’ jobs. The statement also delineates that nurses and the management should work together to create a culture of respect and safety. Lastly, the position statement supports the development of evidence-based strategies to mitigate workplace violence. Therefore, both organizations encourage healthcare providers to combat workplace violence through proper regulations.

Safety Policies and Protocols for Preventing and Responding to Violence Against Healthcare Workers

Safety policies and protocols are necessary to prevent and respond to workplace violence against healthcare providers. Therefore, collaboration and commitment of healthcare workers and managers in eradicating workplace violence ensure that the problem is resolved across different settings, from the emergency department to patient discharge procedures. Working together also makes worksite analysis efficient, as all risk factors that foster workplace violence, including free hospital movement and the possession of weapons in the healthcare setting, will be addressed. Such safety policies and protocols make it easy for managers to develop preventive strategies, including intensifying security staff and training them to identify violence and take appropriate action. Safety and health training of caregivers is also essential since it raises awareness of the appropriate actions to take when facing workplace violence.

Workplace violence between patients and caregivers has been outlined as a serious problem in society since it inflicts physical and psychological harm to the latter, thereby deterring their quality of care and performance. The political and legal factors that facilitate workplace violence in healthcare settings are the understaffing of nurses, inadequate healthcare resources, the poor allocation of funds, the Patient Protection and Affordable Care Act, lack of warning legislation signs in hospitals against workplace violence, and the absence of clear legislation for violence prevention and incident reporting. Nonetheless, OSHA regulations and the ANA position statement have been developed to address the problem of workplace violence in healthcare. They encourage healthcare providers to work together with the management to address and prevent the discussed issue from happening.

📎 References

1. Blando, J., Ridenour, M., Hartley, D., & Casteel, C. (2015). Barriers to effective implementation of programs to prevent workplace violence in hospitals. Online Journal of Issues in Nursing, 20(1), 1–11. https://doi.org/10.3912/OJIN.Vol20No01PPT01 2. Bureau of Labor Statistics. (2016, April 25). Hospital workers suffered 294,000 nonfatal workplace injuries and illnesses in 2014. Retrieved from https://www.bls.gov/opub/ted/2016/hospital-workers-suffered-294000-nonfatal-workplace-injuries-and-illnesses-in-2014.htm 3. Papa, A., & Venella, J. (2013). Workplace violence in healthcare: Strategies for advocacy. Online Journal of Issues in Nursing, 18(1), Manuscript 5. https://doi.org/10.3912/OJIN.Vol18No01Man05 4. Saltzberg, C. W., & Clark, C. M. (2015). A bold call to action: Mobilizing nurses and employers to prevent and address incivility, bullying, and workplace violence. American Nurse Today, 10(8). Retrieved from https://www.myamericannurse.com/bold-call-action-mobilizing-nurses-employers-prevent-address-incivility-bullying-workplace-violence/ 5. Speegle-Clark, K. (2013). Violence in the workplace: A prevention program for healthcare workers. Retrieved from ProQuest Dissertations and Theses database.

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Article Contents

Understand the threats and public health dimensions of violence against hcws, policy recommendations, acknowledgements.

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Violence against healthcare workers is a political problem and a public health issue: a call to action

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Ellen Kuhlmann, Monica Georgiana Brînzac, Katarzyna Czabanowska, Michelle Falkenbach, Marius-Ionut Ungureanu, George Valiotis, Tomas Zapata, Jose M Martin-Moreno, Violence against healthcare workers is a political problem and a public health issue: a call to action, European Journal of Public Health , Volume 33, Issue 1, February 2023, Pages 4–5, https://doi.org/10.1093/eurpub/ckac180

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Violence against healthcare workers (HCWs) strongly increased during the COVID-19 pandemic and this trend seems to continue. 1–3 The attacks have exacerbated occupational stress and the physical and mental health risks of individual HCWs while also creating new threats for healthcare and societies. The violence has spilled over to social media and the private sphere and created new forms of hate crimes and harassment. 4 Live-threatening physical aggression, primarily known from war and conflict settings, now occurs in ordinary workplace settings. 5 International estimations highlight that about every second HCW globally have been affected by violence once in their work lives 6 and up to 38% suffer physical violence at some point in their careers. 1 The frequency and patterns may vary between countries, but violence against HCWs is now also a problem in countries with developed healthcare systems and high levels of trust in institutions and professionals.

The COVID-19 pandemic emerged as a focal point for this violent trend and created new areas of confrontation. The reasons behind the violence are complex and the threats are not limited to HCWs and the workplace. Violence against HCWs is often aimed at the healthcare system and their political representatives and, finally, the democratic state and humanitarian values. Violence seeks to destroy trust in health policy and hamper the right to health for all. Furthermore, it is an attack on democratic states, humanitarian values and civil society.

Systematic monitoring and data are still poor, but the World Health Organization (WHO) and other international organizations and professional associations have taken action. 1 , 6–9 Recently, the ‘Framework guidelines for addressing workplace violence in the health sector’, developed jointly by WHO, International Labour Organization, International Council of Nurses and Public Services International to support the development of violence prevention policies in non-emergency settings and document and research violence in such settings, have become available. 1 However, no protective measures and prevention policies have been implemented so far. Most importantly, violence against HCWs is not adequately recognized as a political issue and public health crisis. 3 , 5 It is largely absent from health workforce policy and the European and national pandemic recovery plans and debates over health system resilience.

This Commentary seeks to address the complex political and public health dimensions of violence against HCWs and highlights the need for action. We argue that public health can, and should, play an important role to raise awareness and improve protection of HCWs, connect different stakeholder groups and establish coordination across sectors and policy areas. A transsectoral and multi-professional governance approach may help us to better understand the different forms of violence and the factors that worsen the attacks. Four major target groups of violence can be identified for non-conflict settings. The situation of HCWs in war and conflict regions is not considered in this work, but it should be mentioned that this group also needs greater public health attention and solidarity.

Frontline HCWs

During the pandemic, verbal and physical violence against frontline HCWs, especially physicians and nurses but also many others, have strongly increased. 2 , 3 Frontline HCWs were obliged to implement the COVID-19 lockdown and distancing policies in practice, oversee quarantines, check vaccination status and protective mask-wearing, and communicate service delays as well as severe illness and death to patients and family. The violence of patients and relatives towards individual HCWs was often a reaction to these conditions resulting in high levels of frustration, fear and emotionally difficult situations. The result, for many HCWs, was that violence became an everyday threat and part of their routine work. Some frontline HCWs even employed, and paid for, private security services to improve protection. In addition, the levels of stress, exhaustion and burn-out for HCWs dramatically increased, thereby worsening recruitment and retention and exacerbating workforce shortages.

HCWs in emergency care and highly politicized healthcare services

HCWs in emergency care are generally at higher risk for violent attacks. 1 , 2 However, new anti-democratic movements in the form of coronavirus denial and anti-vaccination as well as an increase in right-wing populism and neo-fascism in Europe worsened the situation. 10 A common denominator of these developments is their anti-democratic nature and rejection of scientific evidence, government institutions, equality, diversity and human rights, including the right to health. Within this context, HCWs in emergency care and those providing vaccination, abortion and reproductive health services, among others, as well as services for minority and vulnerable groups (e.g. asylum seekers, migrants, LGBTQ people) became the target and surrogate for attacks on the state and its institutions. A strong and coordinated political response to these attacks is therefore necessary.

HCWs affected by the gender-based and sexual violence dimension

Women account for the vast majority of the health workforce and violence is no gender-neutral threat. 8 Gender-based and sexual violence is widespread and most often affects women HCWs. Unfortunately, there is a severe lack of data, research and knowledge resulting in a scarcity of political will and policy-making. There is an urgent need to break the silence and improve protection and create more sensitivity, 8 also for sexual violence against minority women HCWs and some men.

HCWs affected by the racialized violence dimension

Healthcare systems increasingly rely on migrant HCWs. We can therefore assume that this group is also affected by growing violence. Specific protection may thus be necessary against the backdrop of anti-democratic political movements in some areas. Similar to gender-based violence, data in this area are scarce leading to a lack of political action in the realm of public health.

Prepare HCWs. Integrate violence prevention in education and training, e.g. training in self-protection against violent attacks; coping strategies for mental health and wellbeing; communication strategies to de-escalate violence; team-based multi-professional training models to improve coordinated action— micro-level, actor-centred .

Protect HCWs. Improve the scope and enforcement of existing laws and define violence prevention as a management task; implement zero tolerance guidelines, prevention and protection strategies; establish information, helplines and mental health support— organization and management level .

Establish monitoring and reporting systems, improve research evidence and funding programmes— health policy level .

Engage the public, media and communities, including the police. Improve sensitivity; launch a coordinated campaign— local public policy level .

Strengthen civil society and leadership of international public health organizations to respond with coordinated action— global/EU public health policy level .

Take action against violence on HCWs on all levels of governance, including addressing its gender-based and racialized forms.

We thank Sarada Das for very helpful comments and support.

Conflicts of interest : None declared.

World Health Organisation (WHO) . Preventing Violence Against Health Workers . Geneva: WHO, 2022 . Available at: https://www.who.int/activities/preventing-violence-against-health-workers (31 October 2022, date last accessed).

Brigo F , Zaboli A , Rella E , et al.  The impact of COVID-19 pandemic on temporal trends of workplace violence against healthcare workers in the emergency department . Health Policy 2022 ; 126 : 1110 – 6 .

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International Labour Organisation (ILO) . Joint Programme Launches New Initiative Against Workplace Violence in the Health Sector . Geneva: ILO, 2022 . Available at: https://www.ilo.org/global/about-the-ilo/newsroom/news/WCMS_007817/lang–en/index.htm (4 November 2022, date last accessed).

International Council of Nurses, International Committee Red Cross, International Hospital Federation, World Medical Federation . Violence Against Health Care: Current Practices to Prevent, Reduce or Mitigate Violence Against Health Care . Geneva: ICN, ICRC. IHF, WMF, 2022 . Available at: https://www.icn.ch/system/files/2022-07/Violence%20against%20healthcare%20survey%20report.pdf (30 October 2022, date last accessed).

Women in Global Health (WGH) . #HealthToo. About Sexual Exploitation, Abuse and Harassment in Health, Read Women’s Stories . New York: WGH, 2022 . Available at: https://womeningh.org/read-womens-stories/ (1 November 2022, date last accessed).

European Medical Organisations . European Medical Organisations’ Joint Statement on Violence Against Doctors and Other Health Professionals. 2020 . Available at: https://www.cpme.eu/api/documents/adopted/2020/3/EMOs.Joint_.Statement.on_.Violence.FINAL_.12.03.2020.pdf (4 November 2022, date last accessed).

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• Published: 06 May 2022

Workplace violence against emergency health care workers: What Strategies do Workers use?

• Evelien Spelten 1 ,
• Julia van Vuuren 1 ,
• Peter O’Meara 2 ,
• Brodie Thomas 1 ,
• Mathieu Grenier 3 ,
• Richard Ferron 4 ,
• Jennie Helmer 5 , 6 &
• Gina Agarwal 7 , 8  

BMC Emergency Medicine volume  22 , Article number:  78 ( 2022 ) Cite this article

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Workplace violence by patients and bystanders against health care workers, is a major problem, for workers, organizations, patients, and society. It is estimated to affect up to 95% of health care workers. Emergency health care workers experience very high levels of workplace violence, with one study finding that paramedics had nearly triple the odds of experiencing physical and verbal violence.

Many interventions have been developed, ranging from zero-tolerance approaches to engaging with the violent perpetrator. Unfortunately, as a recent Cochrane review showed, there is no evidence that any of these interventions work in reducing or minimizing violence.

To design better interventions to prevent and minimize workplace violence, more information is needed on those strategies emergency health care workers currently use to prevent or minimize violence.

The objective of the study was to identify and discuss strategies used by prehospital emergency health care workers, in response to violence and aggression from patients and bystanders. Mapping the strategies used and their perceived usefulness will inform the development of tailored interventions to reduce the risk of serious harm to health care workers.

In this study the following research questions were addressed: (1) What strategies do prehospital emergency health care workers utilize against workplace violence from patients or bystanders? (2) What is their experience with these strategies?

Five focus groups with paramedics and dispatchers were held at different urban and rural locations in Canada . The focus group responses were transcribed verbatim and analyzed using thematic analysis.

It became apparent that emergency healthcare workers use a variety of strategies when dealing with violent patients or bystanders. Most strategies, other than generic de-escalation techniques, reflect a reliance on the systems the workers work with and within.

The study results support the move away from focusing on the individual worker, who is the victim, to a systems-based approach to help reduce and minimize violence against health care workers. For this to be effective, system-based strategies need to be implemented and supported in healthcare organizations and legitimized through professional bodies, unions, public policies, and regulations.

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Introduction

Workplace violence against health care workers, by patients and bystanders, is a major problem, for health care workers, organizations, patients, and society. It is estimated to affect up to 95% of health care workers [ 1 , 2 , 3 ]. Emergency health care workers experience very high levels of workplace violence, with one study finding that paramedics had nearly triple the odds of experiencing physical and verbal violence [ 4 ].

The World Health Organization (WHO) categorizes workplace violence into physical and psychological violence, which includes verbal violence [ 5 ]. In practice a distinction can be made between major incidents resulting in injury or death of the worker, and everyday violence. While there is general outrage when there is a major accident [ 6 ], the everyday violence from patients and bystanders (including name calling, spitting) does not get as much attention. Workplace violence against health care workers is unlikely to be eliminated, however, an achievable aim is to design and implement interventions that will reduce and minimize this violence and contribute to a safer work environment.

Many interventions have been developed, ranging from zero-tolerance approaches to engaging with the violent perpetrator. Unfortunately, as a recent Cochrane review showed, there is no evidence that any of these interventions work in reducing or minimizing workplace violence [ 3 ]. The focus of many interventions is on managing violent incidents, rather than preventing or minimizing them. This is evident in the almost universal training of health care workers in de-escalation techniques [ 7 ], indicating a one-size-fits-all approach to violence [ 8 ].

A one-size-fits-all approach has its limitations. Violence from patients and bystanders varies, depending on the type of perpetrator [ 9 , 10 ] or the environment in which it occurs. For example, a standard hospital ward provides a much more controlled environment than the work environment of a (community) paramedic or an emergency department [ 3 ]. Prehospital emergency care workers stand out because of the nature of their work environment which is uncontrolled and often involves acute situations. They have a patient population that is more heterogeneous than a mental health ward or aged care facility. Workers are less likely to have a previous relationship with the patient, unlike a family physician or a dialysis nurse. Additionally, patients and associates present to emergency care with already elevated stress levels [ 11 ]. In recent years, emergency care usage has increased considerably [ 12 , 13 , 14 , 15 ]. Patients engage with emergency care more readily for various reasons. The staffing and resourcing of emergency care is not always in line with the increased use of the emergency health services [ 16 , 17 ].

To design better interventions to prevent and minimize violence, an improved understanding of variations in environments as well as in workers’ approaches to violence is needed.

Previous studies have advocated for the application of a modified social-ecological model to workplace violence prevention efforts. This model presents a series of concentric circles beginning with individual factors in perpetrators or healthcare workers; progressing to factors influencing the relationship between workers and perpetrators; then to factors in the immediate work environment; and finally factors in the wider organization. Identifying risk factors and interventions at each of these levels is important for preventing workplace violence [ 18 , 19 , 20 , 21 ].

For the prevention of workplace violence, it is equally important to investigate what strategies emergency health care workers use to prevent or minimize workplace violence. There have been numerous studies on emergency health care workers’ experience of workplace violence [ 1 , 4 , 22 , 23 , 24 , 25 , 26 ], underpinning the frequent occurrence of violence and the severe impact it has on workers. Limited focus has been on strategies used by emergency health care workers to address violence [ 1 , 27 ] or on the use or impact of these strategies.

In this study the focus is on paramedicine as a distinct work environment. Both paramedics and dispatchers (together referred to as emergency health care workers in this manuscript) from three different jurisdictions in Canada were asked to identify strategies they use in response to violence from patients or bystanders. They were also asked about their experience with these strategies and whether they reduced or minimized workplace violence.

For the purpose of this study, community paramedics were included. Even though they generally do not respond to emergency situations, they do work in a relatively uncontrolled environment, and they usually work alone. These factors introduce a heightened level of vulnerability in violence situations.

The aim of the study was to identify and discuss strategies used by emergency health care workers, in response to workplace violence and aggression. Mapping the strategies used and their perceived usefulness will inform the development of tailored interventions to reduce the risk of serious harm to health care workers.

This study addressed the following research questions:

What strategies do prehospital emergency health care workers utilize against workplace violence from patients or bystanders?

What is their experience with these strategies?

For this study we conducted focus groups with prehospital emergency care workers, using a descriptive qualitative design [ 28 ], as the nature of the study was exploratory.

Study setting

Five focus groups with emergency healthcare workers (paramedics and dispatchers) were held at different locations in Canada: three in Ontario and two in British Columbia. Three groups were in an urban setting and two in a rural setting.

Study sample and recruiting procedure

The local organisations invited their emergency health care workers, either via email, in meetings, or face to face to participate in the focus groups at a set time, resulting in random sampling. The only inclusion criterium was being an emergency health care worker. The number of focus groups was determined by the number of organisations that agreed to participate. The number of participants was in theory capped at 10–12 to give all participants the opportunity to participate fully. A Participant Information Statement was provided, which explained the purpose of the study, the voluntary nature of participating and the role of the researcher. Potential participants given the opportunity to ask questions and discuss the information with others if they wished.

Data collection procedure

The focus groups had three to six participants (see Table 1 ) and lasted a maximum of 90 min. They were audio recorded for transcription and analysis. Written consent was obtained at the start of each focus group that was moderated by ES, a female researcher on the project. No additional persons attended the focus groups. To create an environment that was as optimal as possible for participants to unreservedly articulate their responses and to eliminate any impacting power differentials, all persons with line management responsibility did not attend the focus groups. In addition, there was no relationship between the facilitator/principal investigator and the workers. The facilitator was an Australian researcher, the participants Canadian workers. To improve the dependability of the study, an audit trail was kept by the principal investigator including observation notes and a reflexive journal. The reflexive journal was kept, to assist the confirmability of the study [ 29 ].

For the reporting of our results, we used the COREQ standard [ 30 ]. Two broad questions were used to explore the research questions for this study: The participants were asked [1] whether they identified different groups of perpetrators of violence and [2] what their approach was based on their assessment. The term perpetrator is used in this study to describe a person who uses violence and is not intended to invoke legal or criminal connotations [ 31 ].

Data analysis

The focus group responses were transcribed verbatim and analysed using a phenomenological approach, as this approach centres around the lived experience of participants [ 32 ]. Because of the exploratory nature of the study, inductive thematic analysis [ 33 ]; was used as it allowed themes to emerge from the data without the analyst searching for specific answers, which would have been more in line with deductive analysis [ 34 ]. The data were coded by ES and JV.

Ethical approval.

Ethical approval was granted by La Trobe University Ethics Committee under number HEC19009 and by the Hamilton Integrated Research Ethics Board, project 7031.

This ethical approval process was approved and supported by the REBs of the paramedic services involved.

Participants

The five focus groups comprised of 25 participants in total (Table 1 ). They had been working in the field for an average of 13 years (range 5 – 38 years). There was a gender imbalance in the participants sample, with only six female participants, which is reflective of the workforce in this setting [ 9 , 35 , 36 ]. No participants dropped out of the focus groups. Participants had differing opinions across and within focus groups, resulting in lively and unreserved discussions in which everyone expressed their opinions and experiences.

Strategies and experiences

With thematic analysis, six major themes on strategies to prevent and deal with violent behavior were identified: training and other tools, support for refusal of care/staging, prevention strategies, communication between organizations, flagging, and dispatch. One additional minor theme was identified that did not fit within the six major themes: the uniform. The themes are presented and discussed below and supported with quotes in the text and in Table 2 .

Training and other tools

Participants had mixed views on the use and usefulness of training. Some participants would like to get more self-defense or de-escalation training, as this appeared to support them in dealing with violent incidents and made them feel more in control. Others did not think more training would be helpful and even felt this should not be part of their job, as their role was delivering health care, not engaging in the resolution of violent situations. The training could put too much responsibility on the health care worker. There is a risk of making violence incidents their responsibility and even their fault if the violence got out of hand and it was believed they could have done more to resolve it. At the same time, the workers felt they were the victim of the violence. They felt that the organization could take more responsibility, for example there was no clear policy in place on how to deal with violent perpetrators. Irrespective of the training they might have had, most participants mentioned having their own strategies when dealing with violent behavior. They acknowledged that their approach varied, depending on their assessment of the type of perpetrator.

Restraints and sedation were also mentioned as tools to deal with violence. Paramedics saw (soft) restrains as useful but were skeptical that management would allow them.

“But I would also like to see some policy – some training, because we have very minimal training in diffusion. I’m not looking for self-defense stuff, because we shouldn’t be fighting. That’s not my issue.”- Participant Y 

“And I'm not even sure of the actual reporting process for violence in the workplace. To be completely honest with you" - Participant H

Support for refusal of care /staging

Support for refusing the patient health care was a second theme. Most focus groups participants mentioned that they would like to be allowed to refuse the patient care and avoid entering a violent situation. Being allowed to refuse care was seen as clear organizational support for the worker and would contribute to a safe workplace, however participants had doubts this was possible. Regardless of this, some participants did mention they had walked away from violent situations to protect themselves.

“And to have an institutional sort of, even if it is purely theoretical, back-up to my position of saying ‘Sorry, but you’re going to have to leave my ambulance. I’m not going to take you to the hospital today.’ That would go a long way I think. To be supported in that decision.” – Participant C

For paramedics, ‘staging’ outside a patient’s home until police arrived was another clear way to ensure safety. The principle of staging is to keep paramedics safe until police secure a (potentially) violent scene. The paramedics park out of view, leave themselves a buffer (stay out of range) and only respond when the police have reported the scene is secure, making this different to a refusal of care. When a scene suddenly becomes dangerous and paramedics need to retreat, the same principles should be applied. Participants to the focus groups experienced a range of different levels of support from their organization and from dispatch to do this. Dispatch refers to the central staff who receive emergency calls, provide essential pre-arrival advice, and coordinate and dispatch resources and patient transport movements.

Focus groups participants felt supported by dispatch in their decision to stage.

Staging appeared to be an acceptable practice and paramedics agreed that this made them feel safer. However, looking at the bigger picture, participants mentioned that a grey area exists between liability and safety, with the liability potentially falling on the worker in the event that something goes wrong. In common with remarks in relation to training, it appears that workers feel vulnerable on a number of levels: they feel liable, feel they are made responsible, and do not feel sufficiently supported by their organization or by clear policies.

Participants felt a strong duty of care. Besides their own personal safety, participants felt a conflict between staging and the patient’s safety and their duty of care. They mentioned having to find a balance between the two. For workers, this can be described as moral distress.

“So, you’re constantly saying is my job worth potentially staging, is my safety worth potentially saving, and it’s that argument and that call.” – Participant V

“Here actually, if a paramedic calls dispatch and says ‘Hey, I’m just not going. I’m going to stage.’, they’re actually really supportive.” – Participant N

“If there is an immediate and obvious danger – we all just hold off. Sometimes – it’s the balance that you’re talking about. If there is someone going downhill on the other side of that door, and you know it – what are the risks versus you know –” –  Participant W

Prevention Strategies

The focus groups were generally not convinced that advertising or public campaigns to prevent violent incidents were useful. Some participants saw it as a way to shape the public conversation and to educate the general public, noting that the problem extends beyond their workplace. Others did not see it as the solution, they did not believe it was enough to deter people, they did hope that it could increase awareness around the issue. Finally, participants felt it would not change the risk and might even induce patients to become more violent. They felt that saying violence threats will not be tolerated, as some campaigns do, without actually following up on this zero-tolerance strategy, would encourage people to push the boundaries. This lack of action made them feel more vulnerable.

“We prepared a public awareness campaign. […] I mean I don’t think that public advertising is going to prevent violence by any means. But at least they’re aware and it might target people who are just in a stressful situation and are more verbally abusive or harassing or threatening to paramedics.” –   Participant S

“There is a discussion around putting those stop signs in the back of ambulances. And I’m actually against it, personally. Because you see you got them in Australia, and it hasn’t done anything. […] Threats have to be immediate, realistic and enforceable. If we say, violence threats will not be tolerated, you will be kicked out the ambulance. Somebody reads that and goes ‘Okay, make me.’” – Participant P

Communication between organizations

Communication between organizations was a fourth identified theme. Participants commented mostly on a lack of information provided to them which could create unnecessary risks. For example, between hospitals, flagging, discussed in more detail below, was not communicated.

Participants felt that more information from dispatch or the police could help with decisions around staging and an accurate risk assessment of the scene. Others preferred to know less when staging, as it reduced the risk of moral distress. Again, this theme was related to the responsibilities of a paramedic. Some participants felt that they were called to emergency where the police should have been first on the scene.

Participants mentioned very good collaboration with their dispatchers, who they saw as very positively contributing toward their safety. Dispatch was seen as diligent and proactive to ensure that the paramedics were safe and were provided with complete information.

A final issue around communication came from the community paramedics, who mentioned that there is often insufficient information in relation to a transport patient; information can help to identify preventable risk.

“And it’s a difference if we have more information from dispatchers. Did she decide to pick up the phone and call for help? That’s a different mentality, because now they are asking for help versus somebody interrupted their plan. Now they’re angry. So, we don’t have access to that.” – Participant Y

“All I know it’s a horrible system where the police have so much [more] information than us on every address.” – Participant Y

“Generally speaking, when we go to a place, like a known drug dealers house or something that police are aware of, they’ll let us know. And usually they’ll say don’t enter the building until police have arrived.” – Participant V

“The call takers are really diligent at trying to work out if there is any risk for us. Which I appreciated.” – Participant B

“One of the biggest places there where we see a gap is in information sharing. […] I think in lot of cases there is not sufficient information transferred from a sending facility in regard to the patient.” – Participant R

Flagging was identified as a distinct organizational theme which is why we identified it as a separate theme. It is a strategy to signal repeat offenders. Flagging means that if a specific patient calls for paramedic help or presents to a hospital, it should alert the emergency health care worker, if they have been known to have been previously violent. One service, which had the dispatch as part of the service, felt that this was useful, as it allowed the dispatchers to inform paramedics of known or documented dangers associated with a given address. But other participants mentioned that it was a difficult process to get in place, often relating this to reluctance from the organization to allow flagging as a strategy.

“What we do tend to do with our dispatch is that if we’ve gone to a location where we had a violent encounter, we’ll flag that with our dispatchers so future calls they can let them know that this patient has a history of violence against emergency personnel.” – Participant V

“So, one of the things that we historically had trouble with is reluctance from some parts of the organization to what we call as flagging an address.” –   Participant P

Two elements within the theme dispatch were identified. The central role of dispatch emerged as important with the paramedic participants. When communication and collaboration with dispatch were good, dispatch was seen as ‘the first line of defense’. They were seen as being able to provide crucial information, because they had a conversation with the people on the scene. As a second element, in our study, it also became apparent that dispatchers deal with a lot of verbal violence. It was mentioned that since dispatchers do not get physical injuries, their exposure to violence may not be fully acknowledged and nothing is necessarily going to keep them from coming back, even though they might have been affected mentally. Integrating back into dispatch was considered to be challenging, as dispatchers cannot assess beforehand, when they accept a call, what is on the other end of the line.

“Because they’ve had a conversation with the people on scene already. And nobody else has at that point, right? They’re the only ones that have that information. So there is a trust factor that has to exist between our dispatch and us.” – Participant V

“So for us – we’re not dealing with face-to-face violence, but you’re observing that. And we get attacked verbally.” – Participant M

“There is no riding third man in Dispatch. There is no option to know this kind of call is going to trigger me, so I’m not going to take any of those kind of calls. You don’t know. Before you answer, you have no idea what you’re getting into.” – Participant M

The uniform

The paramedics uniform was seen as an issue by some of the participants as in one province they look very similar to police. This could sometimes cause potential danger and inhibit the paramedic’s capacity to provide care. Others mentioned that their uniform gave them a, what they saw as, false sense of security as paramedics were highly respected in the area.

Main findings

This study focused on the use of strategies to deal with violence and the experience with these strategies. Participants identified several commonly used strategies to prevent and minimize violence from patients and bystanders, that are utilized by emergency health care workers. While all participants identified similar strategies, there were opposing views in relation to all strategies, often relating to their experienced usefulness, appropriateness, and legitimacy.

The results show that emergency or first responder work environment is distinctly different to the more controlled environment of a hospital ward when it comes to both exposure to violence, and the capacity to reduce and minimize violence. While the study samples were small, they were diverse and included both urban and rural settings. This paper reiterated that violence has a serious impact on emergency health care workers, to the point where some workers would like to have the option to refuse care. This is a very strong indication of how serious this problem is, as it has already been identified that the duty of care weighs very heavily on all health care workers [ 9 ].

Interpretation of the findings

The results of this study highlighted several issues around violence at work that are discussed more in-depth below.

The social- ecological model of workplace violence

The social-ecological model of workplace violence [ 21 ] was a fitting framework for our results. The model aligned well with the themes identified through our analysis. The clearest indication appeared to be that, when applying the results to the model of workplace violence, most interventions fit within the work environment level and participants felt the responsibility sits at the individual level. At the same time the participants were seeking support and clarity around interventions at the organizational level. A suggestion for consideration is to include an overarching ‘societal level’ to the model, as this type of workplace violence has a strong societal component [ 37 , 38 , 39 ]. Examples of interventions at this level were the public campaigns. And although these campaigns were not considered to be very effective, participants did agree on the importance of raising workplace violence as an issue with the general public.

The focus group participants identified a variety of different strategies based on what they feel is available or has evolved over time as seemingly useful; often these options are more readily based on anecdote than evidence. The suggested strategies appeared to be specific for an emergency health care setting: e.g., staging, flagging and collaboration with the police. This differs from the standard strategies used in other settings, for example psychiatric nurses, would focus on risk assessments and de-escalation techniques [ 40 ]. Many participants discussed the value of education and training, however they stressed that this should simply be one component that complements a system of violence prevention. As mentioned in the introduction, training is often seen by organizations as a one size fits all tool to prevent violence. In this study, participants saw training as a tool for the worker to keep themselves safe and to prevent violence. Although participants had mixed views about extending the training to self-defense training. While participants discussed the value of training, a second recent Cochrane review found that, while training and education may result in a possible increase of personal knowledge and positive attitudes, it did not have an effect on workplace aggression directed towards health care workers [ 41 ].

System-based approach to violence

The study results indicate that, when looking at the different levels of violence, dealing with violence must be integrated into the organization, rather than being made the individual responsibility of the worker, who is in essence the victim in this situation. Most of strategies identified, such as flagging, staging and collaboration, reflect a use of the system, as opposed to making the individual worker (the victim) responsible for an adequate approach through training. This system-based approach must be addressed at the organizational level, providing clarity on policies and procedures. In addition, effective collaboration outside of the health system is reliant on clear roles and responsibilities. For example, the participants had differing views on their collaboration with the police. Some stated that paramedics are sometimes called to a situation that the police should visit first, given their broader authority to act. This is interesting as the trend for mental health calls is to reduce reliance on police. In many parts of the world paramedics are teaming up with social workers or mental health nurses to respond to mental health calls [ 42 , 43 ]. Attention to the types of perpetrators may support the organization of these responsibilities.

Importance of dispatch

Dispatchers play a pivotal role in the system of violence prevention for paramedics. Dispatch could provide relevant information and was a point of contact to discuss and even legitimize an approach to a situation. The results highlighted that dispatchers themselves are subject to (verbal) violence with little recourse. Return to work is challenging as they do not know what situation they might land themselves in before they pick up the phone, there is no buffer. In addition, their exposure rate is significantly higher than paramedics. Whereas a paramedic may do 6 to 8 calls in a standard 8-h shift, a dispatcher may take that many in an hour, often in rapid succession. In addition, research has shown that verbal assault is the most common form of violence [ 1 ]. Call-taking and dispatching has been described as invisible work; the stressful nature of their work needs to be recognized with adequate support [ 44 , 45 , 46 ].

Establishing systems of support

The emphasis on systems, organizations, and collaboration was present in many responses, including accepting the usefulness of public campaigns, if these are followed up with a consistent and consequent system response. Any response to violence needs to be part of a support system at the organizational level and needs to be ratified and backed by the organizations involved, not only by a hospital or health care organization but also by the professional and industrial bodies of emergency health care workers. Commitment and endorsement of management is as important to the effectiveness of workplace violence prevention as the prevention strategies themselves [ 47 , 48 ]. A lack thereof can seriously impact the health and well-being of the worker and act as a barrier to workplace violence prevention [ 49 ]. 

Strengths and limitations

While the study samples were small, they were diverse and included both urban and rural settings. The study is not supported by quantitative data, but the qualitative approach provides deeper insight into the experiences of pre-hospital workers with violence. In addition, the results aligned well with the social-ecological model of workplace violence. The prehospital perspective compliments similar research conducted in emergency departments.

Conclusions

This study demonstrates that emergency health care workers use a variety of strategies when dealing with violent patients or bystanders. Most strategies, other than generic de-escalation techniques, reflect a reliance on the systems the workers work with and work in. This supports the move away from focusing on the individual worker, who is the victim, to a systems-based approach at the organizational level to help reduce and minimize violence against health care workers. For this to be effective, system-based strategies need to be implemented and supported in health care organizations and legitimized through professional bodies, unions, public policies, and regulations.

Availability of data and materials

The datasets generated and/or analysed during the current study are not publicly available due to privacy restrictions but are available from the corresponding author on reasonable request.

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Acknowledgements

To the participating health care organisations for facilitating this study and the staff for their open and frank participation to this study

This project was undertaken as part of an international research visit and was in part funded by an Outside Study Program travel grant from La Trobe University.

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County of Renfrew Paramedic Service, Pembroke, Canada

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School of Population and Public Health, University of British Columbia, Vancouver, Canada

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Spelten, E., van Vuuren, J., O’Meara, P. et al. Workplace violence against emergency health care workers: What Strategies do Workers use?. BMC Emerg Med 22 , 78 (2022). https://doi.org/10.1186/s12873-022-00621-9

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Workplace Violence in Healthcare: Position Statement Essay

Discussions, recommendations.

Workplace violence refers to any physical assault, aggressive behavior, or any inappropriate use of words resulting in abuse in workstations. The workplace takes account of the external environment and the functional areas in an organization. Workplace violence instances include threats of intimidation, fights, suicides, shootings, rapes, harassment along other traumatizing actions. For instance, an individual may attempt to harm a colleague by pushing or striking him or her with the intention of causing bodily harm. Verbal harassment includes false accusations and the use of abusive language (Estes, Chapman, Dodd, Hollister, & Harrington, 2013). Strangers, co-workers, clients, or even personal relationships can instigate aggression. The economic effect of workplace violence in health care settings include lost wages, lost productivity, legal expenses, lost working hours, and damage to property.

Workplace violent behavior has become a compound and risky occupational danger in today’s health care setting. Consequently, the risk arises from exposure to aggressive people and due to lack of well-built violence deterrence programs in the health care environment. Domestic violence also spread out, and it results in the sphere of threat for other workers, visitors, as well as clients. Risk factors in health care violence consist of commonness of handguns and other weapons among patients or friends, increased use of hospitals by the criminal justice system to hold up criminals, lack of follow up for discharged mental patients, unrestricted movement along with pitiable lighting systems (Lipscomb & El Ghaziri, 2013). Vulnerability to violent threats in health care setting requires a detailed analysis and assessment aimed at determining actions needed to minimize the risk. This may involve trend analysis and incident monitoring. Victims and witnesses of workplace violence in the healthcare setting require immediate treatment and counseling to minimize trauma effects.

A stranger who has no legitimate relations with either the employees or organization may cause violence. The central aim is robbery and may be characterized by assaults, deaths, or sexual abuse. Patients who may be violent in nature or that are discontented with services offered may be behind violent acts in hospitals. These patients may be prison inmates or even suspects being pursued by police officers. A co-worker or a past employee may also be involved in workplace violence where he or she brings forth hostile behaviors that result to harm (Estes et al., 2013). Lastly, a person in close relationship may perpetrate workplace violence with the victim because of personal issues. Results of violence include psychological torture, injuries, death, and feelings of intimidation.

To prevent cases of workplace violence, employers should ensure the working environment is free from hazardous elements; this would involve worksite analysis, risk control, education, and training of employees on how to handle equipments along with effective evaluations. Management commitment, as well as employee involvement, should aim at curbing workplace violence. The management is responsible of ensuring reduced violence by seeking employees’ opinions and implementing safety programs. In that regard, employee emotional and physical safety should be guaranteed to promise quality client service. In addition, the management should outline a comprehensive plan to maintain workplace security, assign duties and authority to skilled personnel, and create a zero tolerance policy to workplace violence in the organization (Lipscomb & El Ghaziri, 2013). Employees should be encouraged to report cases of violence to ensure that prompt actions are taken. More so, employees should understand and comply with workplace violence prevention programs and adequately utilize available safety measures. Heath care environment installed with effective alarm systems, metal detectors, emergency rooms, secured nurses’ service counters and closed circuit video recorders guarantee maximum safety.

Estes, C., Chapman, S., Dodd, C., Hollister, B. & Harrington, C. (2013). Health Policy: Crisis and Reform . (6th ed.). Burlington, MA: Jones & Bartlett.

Lipscomb, J. A., & El Ghaziri, M. (2013). Workplace violence prevention: improving front-line healthcare worker and patient safety. New solutions: a journal of environmental and occupational health policy , 23 (2), 297-313.

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Nursing Workplace Violence

• Increase in Nurse Violence
• Influence of COVID
• Long-Term Impacts
• How to Protect Nurses

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While workplace violence in healthcare has been a persistent problem for many years, the rates have spiked during the COVID-19 pandemic. Nurses report escalating rates of COVID-related violence directed at them by frustrated and angry patients and their families.

A 2021 Workplace Health & Safety survey of registered nurses reports that 44% experienced physical violence at least once during the pandemic from patients, family members, or visitors. Over two thirds encountered verbal abuse at least once. RNs who provided direct care for patients with COVID-19 experienced more violence than nurses who did not care for these patients. Nurses also faced difficulty reporting these incidents to management.

The healthcare industry leads all other sectors for non-fatal workplace assaults. Within healthcare settings, violence in emergency departments has reached epidemic proportions during the pandemic. Emergency nurses are particularly vulnerable. Nearly 70 percent of emergency nurses report being hit or kicked at work.

Workplace violence injures healthcare professionals physically and psychologically, resulting in lost workdays, burnout, and turnover. The escalating rates of violence undermine efforts to provide quality patient care and hinder effective responses to combatting the COVID-19 virus.

Fast Facts About Workplace Violence Against Nurses

Sources: Nurses’ Experience With Type II Workplace Violence and Underreporting During the COVID-19 Pandemic | The COVID-19 Effect: World’s nurses facing mass trauma, an immediate danger to the profession and future of our health systems

The State of Workplace Violence Against Nurses

The rates of workplace violence have increased rapidly since the pandemic began. In August 2021 at a hospital in San Antonio , Texas, family members of COVID-19 patients physically and verbally abused healthcare workers for enforcing mask and visiting restrictions. Across the country, healthcare professions who advocate for vaccination and masking mandates have been subjected to online verbal abuse and threats of physical harm toward them or their family members.

Incidents of workplace violence are not restricted to the United States. A patient with COVID symptoms in Naples, Italy grew impatient waiting for treatment and spat at a doctor and nurse. His actions led to a shutdown of the entire ward and quarantine of all staff. In the United Kingdom, patients spat at and verbally abused staff who asked that they wear masks. In Mexico, healthcare workers accused of spreading the virus, have been assaulted and doused with bleach on public streets.

Nurses have become especially vulnerable to these kinds of physical and verbal assaults. Tina M. Baxter, an advanced practice registered nurse who provides consulting services for healthcare organizations, attorneys, and insurance professionals, has personally experienced workplace violence on several occasions.

— “Nurses are the most convenient target as we are with the patients the majority of the time. It is often the nurse who is tasked to enforce the rules about visitation, masking, and other mandates.”

–Tina Baxter, APRN, GNP-BC

She points out that “violence as a whole has increased during the pandemic and the lack of civil discourse in society, too often resorting to violence has become the first instinct instead of the last resort…Nurses are the most convenient target as we are with the patients the majority of the time. It is often the nurse who is tasked to enforce the rules about visitation, masking, and other mandates.”

A recent brief prepared by National Nurses United (NNU) support’s Baxter’s observations. NNU identifies multiple factors fueling COVID-related workplace violence. Nurses constantly face patients and families reacting with anger related to understaffing and increased wait times for care. They frequently deal with aggressive family members who refuse to adhere to visiting and masking requirements. The pandemic fatigue felt by many people and the misinformation spread by untrustworthy media and online outlets have also escalated the violent incidents.

The Influence of COVID on Rising Verbal and Physical Attacks

The recent Workplace Health & Safety survey connects COVID-related violence to the strained relations between nurses and patients. Over 67% of the nurses reported incidents of physical violence or verbal abuse between February and June 2020.

One in ten RNs indicated that reporting the violent incidents to management has become more difficult during the pandemic than before. Underreporting violence during the pandemic may be due to busy workloads, non-standardized reporting procedures, unclear definitions of what constitutes violence, and a perceived lack of management support.

Stressful conditions and more intense patient and family interactions are among the major forces behind the increased risks for aggression and violence toward nurses during the pandemic. Priscilla Grace Barnes, a registered nurse, personal trainer, and nutrition coach, explains that “part of being a nurse isn’t solely caring for the patient, it’s educating and communicating with the family. Many times this communication involves difficult situations around rules and regulations nurses have no control over. We are put in very tough situations.”

The pandemic may have helped spread the mistaken assumption that violence is part of the nursing profession . Many nurses believe that they have a responsibility to provide compassionate care even to those exhibiting violent behavior. As a result, nurses feel they must tolerate unsafe and dangerous conditions, rationalizing that the increase in violence stems directly from the anger and frustration experienced by patients and their families.

The Long-Term Impacts of Nurse Violence

A 2021 research study published in Healthcare reports that nurses who have experienced direct and indirect exposure to workplace violence are two to four times more likely to experience post-traumatic stress disorder, anxiety, depression, and burnout than nurses with no exposure.

According to the International Council of Nurses (ICN), rates of anxiety, trauma, and burnout have spiked dramatically since the onset of the pandemic. ICN data shows that the number of nurses reporting mental health distress has increased from 60% to 80% in many countries. Failure to address these mental health pressures will impact the already existing nursing shortage. ICN estimates a potential shortfall of 14 million nurses by 2030, which amounts to half the current nursing workforce.

— “Working in a hospital I often felt like I was pouring into a cup that had holes in the bottom of it – no matter how much I gave, the cup was never full.”

–Priscilla Barnes

Government, healthcare organizations, and nursing associations must address the pressing need for mental health support and preventive care for nurses. Barnes argues that healthcare facilities must promote psychological wellness to ensure nurse safety: “Nurses are caregivers. We live to serve. But caregivers have to be well. Working in a hospital I often felt like I was pouring into a cup that had holes in the bottom of it – no matter how much I gave, the cup was never full. This only leads to burnout of those who are the lifeline to the hospital – nurses.”

Despite the generally high regard for nurses held by the general public throughout the pandemic, negative public perceptions have also emerged about workplace safety and mental health challenges in the nursing profession. These unfavorable views may deter prospective nurses from entering the field at the time when they are most needed.

Preventing Workplace Violence Against Nurses: What Needs to Happen?

Even before the pandemic, healthcare workers experienced one of the highest rates of workplace violence compared to all other U.S. workers. According to a 2018 report by the Bureau of Labor Statistics , the number of violent injuries has steadily increased since 2011. Because the problem has reached epidemic proportions, nurses, medical facilities, and government agencies must work together to develop concrete measures to prevent the escalation of workplace violence.

— “Workplace violence should not and does not ‘come with the territory’ of being a nurse.”

–Rhonda Collins, DNP, RN, FAAN

One of the first issues to address is the culture of acceptance about violence in nursing. Rhonda Collins, the chief nursing officer at Vocera Communications, a healthcare technology company, cautions that “workplace violence should not and does not ‘come with the territory’ of being a nurse. Healthcare leaders must aggressively act to address this epidemic by validating concerns and ensuring nurses are heard and respected when reporting violent acts.”

What follows are some suggestions for proactive approaches to prevent workplace violence.

Nurses should also be aware of their surroundings, taking into account poorly-lit areas, placement of emergency exits, and crowded public spaces. Nurses can minimize risks by avoiding clothing or jewelry that can be grabbed or pulled. They should exhibit caution when dealing with patients and others who exhibit aggressive verbal cues (e.g., swearing or threatening language), and non-verbal behaviors (e.g., indications of drug or alcohol abuse or throwing objects.)

Nurses should become familiar with their employer’s health and safety policies, report any incidents, and support employees who have experienced violence. Nurses need to become involved in the development of safety policies, procedures, and emergency plans. All personnel should take advantage of available employer-sponsored programs or professional development opportunities on how to respond and prevent violence and how to use de-escalation techniques.

Collins and other nursing leaders argue that healthcare organizations must adopt a “zero-tolerance policy” on workplace violence. In addition to sponsoring educational and support programs, healthcare facilities must develop clear procedures for reporting violent incidents. To combat underreporting, employers must respond to violence seriously. Management has a responsibility to encourage staff to press charges against persons who commit assaults and to support employees when they report these incidents to law enforcement.

Healthcare facilities should upgrade and maintain security procedures and security systems, develop emergency response protocols, and hire sufficient security personnel. Collins suggests that employers provide nurses “with a wearable panic button that calls safety and security personnel so nurses don’t have to reach for a light on the wall when in distress.”

The Occupational Health and Safety Administration does not require employers to implement violence prevention programs, but it provides voluntary guidelines and may cite employers who fail to maintain a safe workplace environment. In early 2021, the House of Representatives passed the Workplace Violence Prevention Act for HealthCare and Social Workers, but it has not yet received Senate approval.

Although no federal laws currently protect healthcare worker safety, several states have passed legislation to protect them from workplace violence. These measures include the establishment of penalties for assaults on nurses, creating a disturbance inside a healthcare facility, or interfering with ambulance service. Only a small number of states require employer workplace prevention programs.

Nurse Resources for Preventing Workplace Violence

In response to the expanding awareness about workplace violence, several government agencies, professional nursing associations, and other special interest groups have developed resources to address safety concerns and violence prevention.

Workplace Violence Prevention Training for Nurses

This interactive course, developed by the National Institute for Occupational Health helps nurses identify risk factors for workplace violence and acquire skills to prevent and manage violent incidents. Nurses can earn continuing education credits by completing this course.

Reducing Workplace Violence with TeamSTEPPS

The Agency for Healthcare Research and Quality provides curriculum materials and webinars designed for clinical teams in a variety of healthcare settings. These TeamSTEPPS resources offer strategies to address difficult situations, reduce the risk of injury, and identify behavioral factors and emotional or psychological issues that lead to violence.

Hospitals Against Violence Workforce and Workplace Violence

Administered by the American Hospital Association, this website provides information on safety resources and practices including preparedness drills and de-escalation training. Featured resources include webinars on creating a culture of safety, mitigating risks, and violence prevention.

Violence, Incivility and Bullying

This website, maintained by the American Nurses Association provides downloadable educational materials, ANA position statements, and issue briefs on reporting incidents of workplace violence and bullying. It also provides links to several violence prevention resources and toolkits.

Workplace Violence Prevention – Interventions and Response Online Course

The Emergency Nurses Association offers several resources to help prevent, mitigate, and report workplace violence. This online course, free to ENA members, helps emergency nurses recognize, prevent, avoid, and respond to violent incidents caused by patients, visitors, intruders, other employees, and management.

Addressing Workplace Violence During COVID and Beyond

The COVID-19 pandemic has exacerbated the problem of escalating workplace violence in nursing. The healthcare industry and the nursing profession must embrace a cultural shift toward accountability and responsibility, providing a safe environment for all healthcare personnel, promoting positive patient care outcomes, and increasing the effectiveness of nursing practice.

Addressing the problem of workplace violence in nursing is in everyone’s interest. Nurses deserve to work in safe settings, performing their duties without fear of injury. Healthcare organizations will face greater nursing shortages due to injury or burnout, impacting the quality and cost of patient care. Effective workplace violence prevention initiatives must include transparent zero-tolerance policies, clear communication and procedures for incident reporting, and educational and support programs.

Meet Our Contributors

Priscilla Barnes

Priscilla Grace Barnes is a registered nurse who graduated with a bachelor of science in nursing and a bachelor of arts in Spanish from the University of Texas at Austin. With over 11 years experience, she has worked from the smallest of patients in the neonatal intensive care unit to the largest of life events with pediatrics and adults in the surgical setting. With a passion for helping others in and out of the hospital, Priscilla also founded Wellness in Bloom(WIB) where she is a personal trainer and nutritional coach. WIB promotes preventative medicine in a friendly environment, by replacing the stress that so often accompanies health and wellness goals with foundational habits that promote sustainability.

Tina Baxter, APRN, GNP-BC

Tina Baxter is an advanced practice registered nurse and a board-certified gerontological nurse practitioner through the American Nurses Credentialing Center. Baxter resides in Indiana and has been a registered nurse for over 20 years and a nurse practitioner for 14 years. She is the owner of Baxter Professional Services, LLC, a consulting firm which provides legal nurse consulting services for attorneys and insurance professionals, among other services. She is also the founder of The Nurse Shark Academy where she coaches nurses to launch their own businesses.

Rhonda Collins, DNP, RN, FAAN

Rhonda Collins, DNP, RN, FAAN has served as chief nursing officer since 2014. As CNO, Dr. Collins is responsible for working with nursing leadership groups globally to increase their understanding of Vocera solutions, share clinical best practices and to bring their specific requirements to Vocera’s product and solutions teams.

Dr. Collins holds a doctor of nursing practice from Texas Tech University Health Sciences Center and a master’s degree in nursing administration from the University of Texas. A registered nurse for 28 years, Dr. Collins is a frequent speaker on the evolving role of nurses, the importance of communication, and how to use technology to improve clinical workflows and care team collaboration.

Reviewed by:

Elizabeth M. Clarke, FNP, MSN, RN, MSSW

Elizabeth Clarke (Poon) is a board-certified family nurse practitioner who provides primary and urgent care to pediatric populations. She earned a BSN and MSN from the University of Miami.

Clarke is a paid member of our Healthcare Review Partner Network. Learn more about our review partners .

Whether you’re looking to get your pre-licensure degree or taking the next step in your career, the education you need could be more affordable than you think. Find the right nursing program for you.

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• Open access
• Published: 03 October 2023

Healthcare workers’ experiences of workplace violence: a qualitative study in Lebanon

• Linda Abou-Abbas   ORCID: orcid.org/0000-0001-9185-3831 1 ,
• Rana Nasrallah 2 ,
• Sally Yaacoub   ORCID: orcid.org/0000-0003-0819-1561 1 , 3 ,
• Jessica Yohana Ramirez Mendoza 4 &
• Mahmoud Al Wais   ORCID: orcid.org/0009-0007-6138-1184 1  

Conflict and Health volume  17 , Article number:  45 ( 2023 ) Cite this article

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The COVID-19 pandemic has brought unprecedented challenges to healthcare workers (HCWs) around the world. The healthcare system in Lebanon was already under pressure due to economic instability and political unrest before the pandemic. This study aims to explore the impact of COVID-19 and the economic crisis on HCWs’ experiences of workplace violence in Lebanon.

A qualitative research design with an inductive approach was employed to gather data on workplace violence through Focus Group Discussions (FGDs) from HCWs in Tripoli Governmental Hospital (TGH), a governmental hospital in North Lebanon. Participants were recruited through purposive sampling. The interviews were conducted in Arabic, recorded, transcribed, and translated into English. Thematic analysis was used to analyze the data.

A total of 27 employees at the hospital participated in the six FGDs, of which 15 females and 12 males. The analysis identified four main themes: (1) Types of violence, (2) Events witnessed, (3) Staff reactions to violence, and (4) Causes of violence. According to the interviews conducted, all the staff members, whether they had experienced or witnessed violent behavior, reported that such incidents occurred frequently, ranging from verbal abuse to physical assault, and sometimes even involving the use of weapons. The study findings suggest that several factors contribute to the prevalence of violence in TGH, including patients’ financial status, cultural beliefs, and lack of medical knowledge. The hospital’s location in an area with a culture of nepotism and favoritism further exacerbates the issue. The staff’s collective response to dealing with violence is either to submit to the aggressor’s demands or to remove themselves from the situation by running away. Participants reported an increase in workplace violence during the COVID-19 pandemic and the exacerbated economic crisis in Lebanon and the pandemic.

Interventions at different levels, such as logistical, policy, and education interventions, can help prevent and address workplace violence. Community-level interventions, such as raising awareness and engaging with non-state armed groups, are also essential to promoting a culture of respect and zero tolerance for violence.

Introduction

Acts of violence in the workplace have far-reaching consequences that can disrupt various aspects of society [ 1 ]. Healthcare workers (HCWs) are often at a higher risk of being subjected to workplace violence, with up to 38% of HCWs experiencing violence at some point during their careers [ 2 ]. The prevalence of workplace violence (WPV) against HCWs was found to be high in Asian and North American countries, psychiatric and emergency department settings, and among nurses and physicians [ 3 ].

The COVID-19 pandemic has aggravated violence against HCWs [ 4 , 5 , 6 ], increasing existing sources of violence and opening new areas of confrontation between healthcare providers, patients, and their families [ 5 ]. From February to December 2020, the International Committee of the Red Cross (ICRC) received 848 reports of violence against HCWs related to COVID-19 across 42 countries. These incidents occurred in various regions around the world, including Europe, Africa, the Americas, and Asia [ 7 ]. A review of incidents from a lower-middle-income country revealed that the reasons for the assaults are varied, including unexpected outcomes or death of a patient, unavailability of resources at the hospital due to overcrowding, miscommunication, and a lack of awareness in society [ 8 ].

A joint study by several international organizations has found that violence against doctors is widespread and has increased since the start of the COVID-19 pandemic [ 5 ]. The study received responses from over 120 organizations and found that 58% of respondents perceived an increase in violence, with all respondents reporting verbal aggression, 82% mentioning threats and physical aggression, and 27% reporting staff being threatened by weapons [ 5 ]. The study highlights the need for concrete action to end impunity for those who are violent and suggests practical solutions, such as improving relations between health personnel and patients and implementing successful strategies from countries such as Bulgaria, Colombia, Italy, Portugal, and Taiwan. The study highlights the need to better understand how violence is affecting healthcare workforce and quality of services and take action to stop it [ 5 ].

WPV is a serious issue in Lebanon, and the healthcare sector is not immune to this problem. A study conducted in 2015 found that 62% of nurses in Lebanon experienced verbal abuse in the past year, while 10% reported physical abuse, including weapon attacks [ 9 ]. The economic crisis in Lebanon, combined with the ongoing COVID-19 pandemic for the past three years, has resulted in an increase in violent acts against HCWs, with hospitals becoming a target for frustrated individuals [ 10 ]. The situation is particularly challenging for Tripoli Governmental Hospital (TGH), which is the second largest public hospital in Lebanon where citizens suffer from low incomes and poverty. Its location is critical, as many armed clashes/hostilities take place in the surrounding area of the hospital, making it more vulnerable to workplace violence [ 11 ]. As HCWs play a critical role in providing essential services to the community and deserve to work in a safe and supportive environment, it is crucial to address the issue of workplace violence and gain a deeper understanding of the issues surrounding violence against healthcare providers in TGH. This study aims to understand HCWs’ perspectives on workplace violence, explore their preferences for interventions to prevent violence, and propose feasible methods to protect HCWs from violence. This research could be a crucial step towards improving the safety and well-being of HCWs in Lebanon and other similar settings.

Study design and setting

A qualitative research design with an inductive approach was employed to gather data on WPV through Focus Group Discussions (FGDs). The decision to initiate the research with FGDs rather than individual interviews was due to several factors including resource availability, research objectives, and the nature of the research question. Starting directly with FGDs was deemed efficient in terms of time and resources, especially when seeking a broader understanding of WPV by facilitating group interactions that stimulate participants to build on each other’s ideas and experiences. Additionally, FGDs can create an environment where participants feel more comfortable sharing sensitive or personal experiences due to the shared context and the support of the group.

The study was conducted at TGH that serves about 638,000 Lebanese (including 244,000 residents of Tripoli), 233,000 Syrian refugees, and roughly 50,000 Palestinian refugees. Approximately 400 healthcare providers (doctors and nurses) work at TGH [ 11 ].

Participant recruitment

To ensure a diverse range of participants based on gender and occupations, we implemented a purposeful sampling procedure. This procedure involved contacting various categories of hospital staff and inviting them to participate in our study. Eligibility was extended to all staff members working within the hospital setting. Invitations to participate were conveyed through phone messages. Staff members who expressed their willingness to participate were subsequently contacted via phone messages to arrange the interview. Additionally, we meticulously planned the FGDs by predetermining the date, time, and location.

Our selection criteria focused mainly on individuals in direct contact with patients due to their unique vantage points and daily exposure to WP incidents providing firsthand perspectives on frontline dynamics. Additionally, administrative and support staff were included to contribute valuable insights into organizational aspects related to workplace violence, enriching our understanding of the broader context within healthcare organizations. These categories were considered most appropriate for our research, as they align closely with our research objectives, allowing us to gain comprehensive insights into WP in the healthcare setting.

The hospital staff who agreed to participate in the study were grouped according to their preferred time during the day.

Four FGDs were conducted for the study, as follows:

A group of female nurses.

Two groups of both female and male nurses.

A group of hospital administrative staff.

Two groups of other support staff including orderlies, lab technicians, cooks, housekeeping.

Data collection

In February 2022, the FGDs were conducted by two investigators in Arabic in a private room at the hospital using a semi-structured interview guide (Appendix 1). Only non-identifiable information was collected and included gender and the participants’ job title (i.e., physician, nurse, paramedic). The interview guide included open-ended questions related to WPV, such as how it is defined, the forms it takes, examples of violent incidents, and the motives of perpetrators. Other questions included the staff’s reaction to the incidents and whether they could have reacted differently or prevented the event from happening. Training of HCWs, preventing violence, and hospital safety regulations were also discussed. The interviews lasted 45 min to an hour on average.

As we progressed through the study, we observed that new information and perspectives related to workplace violence became increasingly scarce. Instead, we encountered recurring themes and insights from participants, indicating that we had comprehensively explored the topic. This consistent repetition of information across participants signaled to us that we had achieved data saturation, where further data collection would likely yield diminishing returns in terms of new insights.

Data gathering tool

The discussions were audio recorded as a means of capturing participants’ voices, experiences, and perspectives in their own words during the FGDs. Following the transcription, the original recordings were securely destroyed to uphold participants’ privacy and ensure the confidentiality of the information shared. This approach aligned with best practices in qualitative research to protect participants’ identities and uphold the integrity of the research process.

Quality control and assurance

The research team rigorously ensured objectivity and impartiality in the formulation of research questions. Questions posed during interviews were deliberately crafted to be objective, avoiding any form of intervention or bias. The primary goal was to explore diverse dimensions of workplace violence and gather information essential for the study. Crucially, the interviewers maintained a neutral stance, refraining from expressing personal opinions or influencing participant responses. Importantly, no pre-existing relationships existed between the interviewers and participants, reinforcing the integrity of the research process. Data collection was conducted in a room within the hospital premises, selected for its convenience. This choice accommodated the participation of hospital staff during their work shifts, facilitating their engagement in the study. All staff members within the hospital, irrespective of their roles, were eligible to participate due to their direct interactions with patients, which made their perspectives valuable to the research objectives. The selection of participants was unbiased, guided solely by their roles in patient care and their exposure to workplace violence incidents.

Ethical considerations

The approval of the Institutional Review Board (IRB) at American University of Beirut (AUB) (SBS-2021-0352) and the internal ethical review board at ICRC was obtained before starting the study (2109-APR). The study was conducted in accordance with ethical principles and guidelines, including informed consent, confidentiality, and the right to withdraw from the study at any time. The participants signed an informed consent form before the discussion, which emphasized the confidentiality of the information they shared. They were also informed that they could withdraw from participating in the study at any time.

Data analysis

Audio-recorded FGDs were transcribed verbatim in the Arabic language. A rigorous manual analysis was undertaken to discern recurring themes, patterns, and insights pertaining to WPV experiences among HCWs. The verbatim transcripts were meticulously reviewed to extract pertinent concepts and phrases, which were then assigned as codes. These codes were subsequently organized into categories within a matrix structure. These categories aligned with overarching themes that were deduced from the research objectives and questions, allowing for a comprehensive exploration of WPV dimensions. The themes and sub-themes identified underwent thorough discussion within the research team to ensure accuracy and robustness. Quotes used in reporting findings were translated to English language.

A total of 27 employees at the hospital participated in the six FGDs, of which 15 females and 12 males. The participants were further categorized into three groups based on their occupations: nurses (14 participants), administrative staff (5 participants), and support staff (8 participants).

The analysis of the information gathered was conducted through a process of coding, sub-theme, and theme development. The coding scheme can be found in Table  1 .

In the following paragraphs, each theme is described in more detail providing sample quotes, where appropriate.

Types of violence

All participants unanimously agreed that any form of aggression experienced while performing their jobs in healthcare settings constitutes violence. This indicates a clear consensus among the participants regarding the definition of violence in the healthcare setting.

Based on the participants’ descriptions, the types of violence experienced in healthcare settings can be categorized into two main forms: verbal and physical. Verbal violence included any communication that is intended to harm or intimidate, such as shouting, swearing, or making derogatory remarks. Physical violence, on the other hand, included any intentional physical act that causes harm or injury, such as hitting, kicking, or pushing. Some participants also mentioned the potential for nonverbal or subtle forms of violence, such as body language or tone of voice, which can convey aggression or hostility. Additionally, some participants identified the use of weapons or threats as a form of violence. While most of the participants focused on the violence that they can face from the patients and their families, some mentioned that violence can be addressed from their colleagues as well. Moreover, it was acknowledged that violence in healthcare settings can also originate from staff members towards their patients.

Events witnessed

All staff members have witnessed violence at work that ranged from verbal abuse such as being threatened, shouted at, and being cursed, to being punched or slapped and sometimes even physical injury in the form of bone fractures. It is important to note that the type of violence targeting males and females differed. Males were more likely to experience physical violence. In contrast, females were often targeted with verbal abuse, though they were not immune to physical violence either. Additionally, weapons were brought into the hospital and used against the staff, further exacerbating the risk and harm faced by everyone involved.

A nurse that was working in the Emergency Department (ED) was present during an event when a family member of a patient who was seeking care for a stabbing injury in the back was threatening to blow the ED with a bomb if his relative would have died or “ does not leave the hospital walking on his legs ”. He even shot the roof of the ED with the weapon he was holding.

The participant verbalized the following words:

“ It was one of the scariest moments of my life… my colleague and I had to help the bleeding patient, but we were hiding afraid to die… If my parents knew what I went through that day, they would have not allowed me to go to work again ”.

Another participant described being punched in the face by someone who came to the blood bank asking for O negative blood units. The lab technician ended up giving him a unit of blood from any type due to his fear. He mentioned:

In times like that, all you think about is how to save yourself, your life, so that you remain available next to your family… .

Almost half of the participants recalled a recent event experienced by a nurse at the Obstetrics and Gynecology (OBGYN) unit. The family members of a patient broke the fingers of the nurse for not being able to insert an IV line directly to the patient.

Administrative staff have also been subject to violence with four out of five having experienced violent episodes. The violence they encounter is primarily in the form of shouting and damage to the health facility and equipment causing destruction of glass and equipment in their vicinity.

“ We’re used to this kind of violence, we face it daily ”, they said.

Violence has been observed by staff across all categories, including those who do not have direct contact with patients and their families. For example, a cook working in the hospital’s kitchen was shouted at by a patient’s family member for not providing food, even though the patient was under medical orders not to eat due to a recent surgical operation. Additionally, a pharmacist was threatened with physical harm in the pharmacy department if they did not provide narcotics to an aggressive individual.

Some participants mentioned that verbal aggression between staff members may occur, but they are usually resolved immediately without further escalation. Additionally, one participant noted that in some cases, staff members may raise their voices and behave inappropriately towards patients and their families, which could be attributed to the high levels of stress they are experiencing.

“ We are all stressed, sometimes we shout at patients’ families or our colleagues due to the stress we are enduring inside and outside the hospital environment ”.

Causes of violence

Staff reported the causes that could potentially lead to violent incidents in hospitals which can generally be divided into two categories: hospital-related and patient-related.

Hospital-related

One of the main causes that staff members at the hospital cited for potential violence was the inadequate number of security guards. With only two guards stationed at the entrance of the hospital, there was concern that they would not be able to effectively respond to any violent incidents that might occur. Additionally, even though at the hospital’s parking premises there is an army checkpoint; they are not authorized to intervene in such situations, further exacerbating the security issue.

Another reason mentioned by the administrative staff was the laborious and protracted billing procedure for outpatients. To bill the patients, the paperwork needs to be physically transported across several departments, such as pharmacy, laboratory, and imaging, which is a manual process. This process is time-consuming which adds frustration to the patient and his family and can sometimes escalate into violence.

The lack of a clear visitation policy was also a concern raised by nurses at the hospital. Without clear restrictions on who can visit patients and when, anyone can enter the hospital at any time, including individuals who may be carrying weapons.

Patient-related

According to the TGH staff, the main reason of violence in the hospital is attributed to the financial status of the patients. As a public hospital, many patients expect to receive free treatment. However, when informed of the costs associated with their care by the admitting department, they become overwhelmed and agitated, which can escalate to violent behavior. Additionally, the hospital’s location in an area with a culture of favoritism contributes to some patients’ belief that they can obtain special treatment by shouting and threatening, which may also contribute to incidents of violence in the hospital.

One of the staff said that “ the clients of the hospital know that if they shout and threaten, they will get whatever they want ”.

The insufficient medical knowledge of patients and their families is identified by almost all participants as a significant factor contributing to violence in TGH. Due to their limited understanding of the disease, patients and their families have unrealistic expectations of the healthcare staff’s ability to maintain the patient’s life, which can escalate to violent conduct. Furthermore, the COVID-19 pandemic has worsened this situation, as participants noted that the lack of comprehension of this novel disease has also played a role in violent incidents.

“ Families and patients do not understand why they cannot see their relative at isolation, and that makes them aggressive ”.

Staff reactions to violence

The staff collectively agreed that the best way to deal with violence is to either submit to the aggressor’s demands to avoid being subjected to violence or to physically remove themselves from the situation by running away. Two nurses working at the pharmacy department described how nurses from the Obstetrics and Gynecology department ran away from their unit to the pharmacy department when they were aggressed by a patient’s family.

Staff members in hospitals often avoid reacting or intervening in violent situations due to their fear of not only being attacked at work but also being followed and harassed on their way to and from work, as they mentioned:

“ In these situations, we just need to protect ourselves… we agree with whatever the aggressor says and do whatever he asks for ”.

The response to violence differs between males and females. Males tend to face the perpetrator and confront them directly, possibly reflecting societal expectations of male protectiveness or assertiveness. In contrast, females tend to prioritize escape and avoidance, preferring not to engage with the perpetrators directly. They may even respond to the perpetrators’ needs, even if those needs are not relevant or urgent, as a means of defusing the situation. Some female staff members mentioned that when a perpetrator attacks the nursing station or arrives angry at a department, their aggression often subsides upon realizing that the entire staff present is female. This observation suggests that the gender composition of the staff can have an impact on the dynamics of the situation, potentially leading to a de-escalation of the aggression.

In cases of violence, staff members seek assistance by calling the few available security guards at the hospital or asking for help from the police, recognizing the importance of external support in managing violent incidents and ensuring the safety of all involved parties.

The study conducted sheds light on the alarming issue of violence against HCWs in TGH. According to the interviews conducted, all the staff members, whether they had experienced or witnessed violent behavior, reported that such incidents occurred frequently, ranging from verbal abuse to physical assault, and sometimes even involving the use of weapons. The study findings suggest that several factors contribute to the prevalence of violence in TGH, including patients’ financial status, cultural beliefs, and lack of medical knowledge. The hospital’s location in an area with a culture of clout and favoritism further exacerbates the issue. The staff’s collective response to dealing with violence is either to submit to the aggressor’s demands or to remove themselves from the situation by running away. In this discussion section, we will examine the implications of these findings and propose recommendations to address this problem.

Our findings are consistent with a recent meta-analysis of 38 studies involving 63,672 healthcare workers (HCWs), which reported high prevalence rates of workplace violence (WPV) among HCWs. The analysis revealed significant rates of physical violence (9%), verbal violence (48%), and emotional violence (26%) among HCWs. Furthermore, the meta-analysis indicated an escalation of WPV, physical violence, and verbal violence during the mid- to late-stages of the COVID-19 pandemic [ 12 ]. These findings emphasize the critical need to address WPV and prioritize the well-being and safety of HCWs. The patients’ financial status appears to be a significant contributor to violent behavior, as many patients expect to receive free treatment at TGH, being a public hospital. However, they become agitated when informed of the costs associated with their care, which can escalate to violent conduct. The cultural beliefs and attitudes of patients towards the hospital staff also play a role in the occurrence of violence. Patients who believe that shouting and threatening will give them preferential treatment may become violent when their expectations are not met. The lack of medical knowledge among patients and their families is also a significant factor contributing to violent behavior. Patients and their families may have unrealistic expectations of the healthcare staff’s ability to maintain the patient’s life due to their limited understanding of the disease. The COVID-19 pandemic has further exacerbated the issue of violence in the hospital, with participants reporting that the lack of knowledge about the new disease has contributed to violent incidents. Working with people infected with COVID-19 is also a factor for violence [ 6 ]. The weakness of the security logistics at the hospital has also been a major reason for violence. The issues of corruption in Lebanon have also affected violence in the TGH. Many participants mentioned that people who commit violence against HCWs at the hospitals are usually covered by political parties. They threat with weapons and use them in the hospital knowing that eventually, there will be no punishment for their actions. The fact that TGH is a public hospital makes it a “punching bag” for the Lebanese patients that are frustrated from the Lebanese Government, so they pour their anger against the corrupted system in Lebanon on the healthcare workers at the hospital.

Differences were observed between males and females in terms of the types of violent incidents witnessed and the corresponding reactions exhibited. Males are more likely to witness and experience physical violence, such as being punched, slapped, or sustaining physical injuries. This could be attributed to societal expectations of male dominance and the perceived need for physical confrontation. On the other hand, females are more likely to encounter verbal abuse and emotional violence. When faced with violence, males tend to confront the perpetrators directly, possibly driven by societal norms of masculinity and the desire to protect themselves or others. In contrast, females often prioritize their safety by opting for escape and avoiding direct confrontation. They may comply with the aggressor’s demands to de-escalate the situation or minimize the risk of harm. These gender-specific responses may be influenced by social conditioning and self-preservation instincts, highlighting the complex interplay between societal expectations, gender roles, and individual coping mechanisms in the face of violence. However, it is important to note that these findings should not overshadow the fact that violence can affect individuals of all genders and that the experiences of individuals may vary widely. Each case should be considered on its own merits, and it is crucial to avoid making broad generalizations based solely on gender. Addressing violence requires comprehensive efforts that focus on prevention, support for survivors, and challenging harmful societal norms and behaviors.

It’s important to note that not all HCWs initially approached for participation in our study agreed to participate to the study. Possible reasons are unavailability during the study period or may be concerns related to the sensitivity of the topic, given that workplace violence is a complex and sensitive issue. We recognize that their non-participation introduces certain limitations and potential biases as their perspectives and experiences, which could have enriched our findings, are not represented. Consequently, we have taken great care to accurately present the data collected from willing participants in a manner that faithfully reflects their experiences within the study’s scope.

Interventions should be implemented promptly to enhance the security measures in hospitals, given the severity of the issue of violence against staff members. To improve security measures at hospitals, various interventions can be implemented at the organizational level. Logistical interventions, policy initiation interventions, and staff education can help prevent workplace violence. One effective logistical intervention is to install metal doors with access restricted to staff ID cards at hospital entrances and unit doors. Additionally, increasing the number of security guards and placing at least one guard on each hospital floor can help limit the number of visitors and prevent unwanted access. Metal detectors at the main entrance can also help prevent visitors from entering the hospital with weapons. At the policy level, visitation restrictions can be implemented, such as limiting visits to two family members per patient. Staff education and training programs can be conducted to prevent and manage workplace violence. Research has shown that staff training for violence prevention and management can reduce the consequences of violence [ 13 ]. Healthcare organizations, policymakers, and the government should work together to implement these interventions to ensure that healthcare workers can provide care safely and without fear of violence. Staff have shown willingness to participate in such training during focus group discussions.

At the community level, raising awareness among the adjacent population about the importance of respecting the hospital’s facilities and staff is one such intervention. This can help the community understand the crucial role of healthcare workers in treating and preventing diseases and promote their protection instead of violation. Another important intervention is to engage with non-State armed groups in the area to prevent violence against healthcare workers. The International Committee of the Red Cross (ICRC) has set an example in 2014 by counseling and meeting with them and signing an agreement to avoid interfering in the hospital’s work and protecting healthcare workers [ 7 ]. These interventions involve all stakeholders in the problem and have shown positive impacts in reducing violence against healthcare workers in recent studies [ 13 ].

Violence against healthcare workers is a critical issue that affects the quality of healthcare services and the safety of both HCWs and patients. Our findings, derived from the perspectives of healthcare workers (HCWs), suggest that the problem of violence against HCWs is multifaceted, with various factors contributing to its occurrence. These factors include patient-related, organizational, and community-related factors. Interventions at different levels, such as logistical, policy, and education interventions, can help prevent and address workplace violence. Community-level interventions, such as raising awareness and engaging with non-state armed groups, are also essential to promoting a culture of respect and zero tolerance for violence. It is crucial for all stakeholders, including healthcare organizations, policymakers, the government, and the community, to work together to implement these interventions to ensure that healthcare workers can provide care safely and without fear of violence or harm.

The authors confirm that the views and opinions expressed in this publication do not in any way constitute the official view or position of the ICRC. Every effort has been made to comply with our duties of discretion regarding activities undertaken during our employment/missions with the ICRC.

Data Availability

The data collected for this qualitative study is not publicly available due to the confidential nature of the information shared by participants. Access to the data is restricted to the research team to maintain privacy and ensure compliance with ethical guidelines.

Abbreviations

Coronavirus disease-2019

Health care workers

Focus group discussion

Tripoli Governmental Hospital

International Committee of the Red Cross

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Acknowledgements

We thank the staff of the TGH who consented to participate in this study and for sharing their stories during such troubled times in Lebanon. We also thank the nursing director who helped with the recruitment and logistics.

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Linda Abou-Abbas, Sally Yaacoub & Mahmoud Al Wais

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Rana Nasrallah

Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and Statistics (CRESS), Paris, France

Sally Yaacoub

International Committee of the Red Cross, Geneva, Switzerland

Jessica Yohana Ramirez Mendoza

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MAW and SY conceived the study idea and designed the study protocol. RN and SY conducted the interviews. RN conducted the transcription, translation, and drafted the manuscript. LAA contributed to the qualitative analysis of the data and assisted with editing the article. JM reviewed the article for important intellectual content. All authors approved the final version submitted.

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Interview Topic guide .

Introduce yourself, provide the consent form .

Collect Demographic information: Gender & job title .

Workplace Violence .

How do you define occupational violence (i.e., workplace violence)? In what forms does it occur? Can you give examples from your experience (whether you witnessed violence or got exposed to it)?

Have you ever been exposed to violence at work/healthcare setting?

Why do you think such aggressive incidents take place? What are the motives of the perpetrator?

How did you react to the incidents that you got exposed to or witnessed? And do you think you could have reacted differently or maybe prevented the event from happening?

Do you think training of healthcare workers in communication/counseling skills, training in managing violence … would help prevent violent incidents?

Do you think it would be useful to increase resources in combating violence; specifically, by increasing security personal and facilities, working conditions and incentives for healthcare workers, and adequate facilities (equipment/medicines/ healthcare workers)?

What rules and regulations are needed to ensure that the environment is safe at the hospital?

How willing are you to engage in specific programs to combat violence? Why are you encouraged and why not?

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Abou-Abbas, L., Nasrallah, R., Yaacoub, S. et al. Healthcare workers’ experiences of workplace violence: a qualitative study in Lebanon. Confl Health 17 , 45 (2023). https://doi.org/10.1186/s13031-023-00540-x

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DOI : https://doi.org/10.1186/s13031-023-00540-x

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Here's How CNOs Can Prevent Workplace Violence and Keep Nurses Psychologically Safe

Analysis  |  By G Hatfield    |    April 08, 2024

Physical and psychological safety should be key focuses for CNOs.

Safety goes beyond just the physical. Nurses must feel psychologically safe as well—they should be able to voice their feelings and concerns without fear.

During the HealthLeaders ’ Nurse Labor and Compensation NOW Summit , Jennifer Croland, vice president and chief nursing officer at OSF HealthCare Saint Francis Medical Center, and Dr. Marie Giordano-Mulligan, vice president for nursing and chief nursing officer at Huntington Hospital Northwell Health, both spoke about how CNOs can help their nurses feel physically and psychologically safe at work.

Workplace violence prevention

Giordano-Mulligan also said they have signage that displays how respect from patients, family, and visitors is a requirement, and that the hospital does not tolerate violence toward the nursing staff or other healthcare workers.

Support is also provided to nurses after incidents occur, in the form of both employee assistance programs and employee health services if injuries are sustained.

"They're also given the option to file a police report as well and press charges," Giordano-Mulligan said, "and we will support them in that because they have that right."

In terms of mental health and psychological safety, Giordano-Mulligan said Huntington Hospital has processes in place for helping nurses improve wellbeing.

"If they need support for any other concerns…there is a process in place to help them with employee support services," Giordano-Mulligan said, "and there's a committee that is very active working with…executive leadership and with team inputs to enhance those processes in the future."

Psychological safety

"I've seen lots more people who are only working for a year and then they're choosing to leave the nursing profession," Croland said.

CNOs are also concerned with the public perception of nursing, and how that contributes to participation in the industry and potentially the culture of a health system.

"If you're on social media at all, you've probably seen the TikTok [videos] that are disparaging to the profession," Croland said, "so we have some accountability, I think, in changing that image of nursing." 

"How do you work in a culture where you can respectfully escalate a concern to another nurse who's working, who may be shutting you down?" Croland said, "and I think transition to practice programs are gaining a lot more traction."

The ANCC has criteria for transition to practice programs that Croland recommended. The criteria exist to help nurses acclimatize better to the profession and become more equipped to deal with the stressors that accompany the job.

"When you think about what we do, it requires high reliability, really high stakes outcomes, [it's] life and death, and that's a lot to put on a young person who's new in their role," Croland said.

CNOs must create environments where nurses can come forward and admit that they are not sure whether they did something right or wrong, or that they made a mistake that affected the patient.

"I think those programs are worth their weight in gold," Croland said, "they have demonstrated successes with reducing turnover, increasing retention, and really keeping people within the profession of nursing."

G Hatfield is the nursing editor for HealthLeaders.

KEY TAKEAWAYS

Health systems should invest in technology to help keep their nurses safe, and provide support programs for them after workplace violence incidents occur.

CNOs must create work environments where nurses can voice concerns without fear of judgment or retaliation.

Transition to practice programs are useful tools for training nurses on how to communicate problems and acclimatize to the nursing environment.

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• Open access
• Published: 08 April 2024

Preventing workplace mistreatment and improving workers’ mental health: a scoping review of the impact of psychosocial safety climate

• Mustapha Amoadu 1 ,
• Edward Wilson Ansah 1 &
• Jacob Owusu Sarfo 1  

BMC Psychology volume  12 , Article number:  195 ( 2024 ) Cite this article

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Work environment is rapidly evolving, unfortunately, it is also becoming increasingly hostile for workers due mostly to common psychosocial hazards. This situation is posing significant challenges for organisations to protect the psychological well-being of their workers. Hence, this review aims to map studies to understand the influence of psychosocial safety climate (PSC) on workplace mistreatment and mental health of workers.

The guidelines outlined by Arksey and O’Malley were adopted for this review. PubMed, Scopus, Web of Science, JSTOR, Google and Google Scholar were searched for relevant papers. Only peer-reviewed studies that measured PSC using PSC-12, PSC-8 or PSC-4 were included in this review.

Thirty-eight studies met the inclusion criteria. This review found that PSC has a negative association with workplace mistreatment such as bullying, harassment, violence, discrimination and abuse. Further, PSC has a positive association with psychological well-being, personal resilience and hope. Low level organisational PSC also promotes psychological distress, stress, depression, cognitive weariness and emotional exhaustion. The buffering effect of PSC is well-established. Moreover, PSC mediates the association between health-centric leadership and workers’ psychological health problems. The inverse relationship between PSC and depressive symptoms was stronger for females than males.

Organisations should prioritise training and development of supervisors to enhance their supportive skills, encourage respectful behaviour, encourage the use of resources promote open and bottom-up communication and provide guidance on conflict resolution. By promoting a high PSC context, organisations can create a culture that discourages mistreatment, leading to increased employee well-being, job satisfaction, and productivity.

Peer Review reports

Introduction

Work environment globally is rapidly evolving, but it is also becoming increasingly hostile for workers. Recent evidence from the International Labour Organisation (ILO) indicates that about 23% of workers have experienced violence and harassment at work, encompassing physical, psychological, and sexual abuse [ 1 ]. This disturbing statistic reveals that more than one in five people in employment have encountered workplace violence and harassment, posing significant challenges for organizations to protect the psychological well-being of their workforce. There is also a growing realization of the need to understand the influence of the psychosocial work environment on workplace mistreatment and mental health. The World Health Organisation (WHO) and ILO have jointly reported a global increase in occupational morbidity and mortality resulting from a poor psychosocial work environment [ 2 , 3 ], emphasising the importance of exploring the concept of psychosocial safety climate (PSC).

PSC is an organisational culture that prioritises workers’ psychological health and safety at the workplace [ 4 ]. Thus, PSC refers to the shared perceptions of workers concerning workplace policies, practices, and procedures that are designed to protect and promote their psychological well-being [ 5 ]. It encompasses a range of organisational factors including leadership commitment to workers’ well-being, job design, organisational justice, social support and overall climate of trust and respect at the workplace [ 6 ]. A high PSC context emphasises the importance of fostering a psychologically healthy work environment, where workers feel safe, supported, valued, treated fairly and respected [ 7 ], thus, lowering the tendency of mistreatment of workers.

Workplace mistreatment refers to any form of harmful, abusive, or disrespectful behaviour that occurs in the work environment [ 1 ] This includes but not limited to bullying, harassment, violence, abuse and discrimination [ 1 ]. Workplace mistreatment has gained significant research and policy attention due to its detrimental effects on both workers and organizations [ 1 ]. Victims of workplace mistreatment often experience poor mental health, job dissatisfaction and impaired productivity [ 8 ]. Recognising the crucial role of the PSC in mitigating workplace mistreatment and protecting workers’ mental health has become a pressing concern for researchers, industries and policymakers [ 8 ]. For over a decade of research into PSC, identifying and synthesising studies that have explored PSC in reducing workplace mistreatment and improving mental health is noteworthy. Thus, this scoping review aims at mapping existing studies to provide a comprehensive understanding of the influence of PSC on workplace mistreatment and mental health on workers. The purpose is to make recommendations for future research and systematic reviews. This review will also help organisations, managers and policymakers to develop evidence-based strategies and interventions that promote a PSC work-context that fosters a respectful and supportive work environment and safeguard workers’ psychological well-being. Also, this review aims to provide evidence that is useful in promoting a healthy and decent workplace that eliminates all forms of workplace mistreatment and mental health stressors.

The guidelines outlined by Arksey and O’Malley [ 9 ] were adopted for this scoping review: thus, identifying and stating the research questions, identifying relevant studies, studies selection, data collection, summary and synthesis of results and consultation. Therefore, we formulated research questions based on the Population, Concept and Context (PCC) framework. The following questions guided this scoping review:

What is the relationship between PSC and workplace mistreatment?

What is the relationship between PSC and mental health parameters?

What is the mediating and moderating role of PSC in improving workers’ mental health and reducing workplace mistreatment?

Search for relevant papers was conducted in four main databases (PubMed, Scopus, Web of Science, and JSTOR). Google and Google Scholar were explored for additional papers. Reference lists of eligible records were also checked for relevant papers. The authors created a search technique that used a combination of controlled vocabularies like Medical Subject Headings (MeSH). Keywords for each of the four major electronic databases (PubMed, Scopus, Web of Science and JSTOR) were also created to address the research questions and identify relevant literature. Table  1 presents the search strategy conducted in PubMed and other databases. The search strategies were informed by PCC. The context was not limited to a specific country or region since this review was given a global focus. The search strategy used in PubMed was then modified for search in other databases. The authors used three keywords in their search strategy (1) psychosocial safety climate, (2) workplace abuse and (3) mental health. The search for relevant papers started on March 12, 2023, and ended on July 1, 2023. Chartered librarians at the Sam Jonah Library, University of Cape Coast were consulted.

Mendeley software was used to remove duplicate records. Ten graduate students were trained and supervised by MA to screen titles and abstracts for full-text-eligible records. This was done to enhance efficiency in the screening process and allowed for a more thorough and expedited review of titles and abstracts to identify records eligible for full-text examination. Authors checked the reference list of full-text records to identify additional eligible records. Eligible full-text records were then screened independently by MA and JOS and supervised by EWA using the eligibility criteria presented in Table  2 . Weekly meetings were used to resolve disagreements identified during the screening process.

Data extraction was handled independently by two independent researchers (MA and JOS) and supervised by EWA. This was done to ensure that accurate and reliable data were extracted for this review. Disagreements during the data extraction phase were handled during weekly meetings. Authors extracted data on authors, the country where the study was conducted, year of publication, purpose of the study, study design, population, sample size, measure of PSC and study outcomes. Finally, thematic content analysis was conducted by the authors based on the research questions. The analysis involved identifying recurring themes relevant to the research questions. This process included organising and categorising data to extract meaningful patterns and insights from the extracted information. The search results, characteristics of reviewed studies and thematic analysis were presented.

Search results

Search conducted in the four main databases produced 4,621 records and additional 29 records were retrieved from Google and Google Scholar. The Mendeley software was used to remove 742 duplicate records. After title and abstract screening, 3,820 records were removed because they were not relevant to this review. Additional 5 records were retrieved through reference checking of eligible studies and 93 full-text records were screened for eligibility. Finally, 38 full-text records were included in this scoping review and the remaining 55 full-text records were removed because they did not report on variables of interest. The search results and screening process is presented in Fig.  1 .

PRISMA flow diagram of search results and screening process

Characteristics of reviewed studies

Reviewed studies collectively sampled 53,733 workers. A cross-sectional survey design was mostly used in conducting these studies (See Fig.  2 for details). A few (6) of the studies were published in 2021 (See Fig.  3 for details), with about half (19) conducted in Australia (See details in Fig.  4 ). Most of the studies we reviewed sampled general working population (16) and healthcare providers (11) (See details in Fig.  5 ). Characteristics of reviewed studies are presented in Supplementary File (Table S1 ).

Study designs of reviewed studies

Year of publication of included studies

Map showing countries and continents where reviewed studies were conducted

Occupational groups explored by reviewed studies

Influence of PSC on workplace mistreatment

Evidence indicates that PSC has a direct and significant influence on workplace mistreatment. For instance, reviewed studies reported that a high PSC work context provides a favourable work environment that helps eliminates or reduces workplace bullying among workers [ 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 ]. Also, workplace violence [ 8 , 10 ] and abuse [ 18 ] are common in a low PSC context. In addition, studies further highlighted that workplace harassment [ 10 , 11 ] and discrimination [ 18 ] are less common or eliminated in a high PSC context.

Influence of PSC on workers’ mental health

Evidence established that PSC directly improves workers’ mental health. For example, evidence is consistent that high PSC context improves psychological well-being [ 14 , 19 , 20 , 21 ] and reduces psychological distress [ 4 , 18 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 ]. Furthermore, it is indicated that low PSC work exposes workers to emotional exhaustion [ 4 , 16 , 22 , 25 , 30 , 31 , 32 ], stress [ 33 , 34 ], cognitive weariness [ 35 ] and depression [ 23 , 36 , 37 , 38 ]. For instance, a study reported that the inverse relationship between PSC and depressive symptoms was stronger for females than males [ 36 ]. Moreover, a high PSC context makes workers more assertive [ 39 ] and resilient [ 40 ] and presents opportunities for hope [ 40 ]. We present thematic analysis of the influence of PSC on workplace mistreatment and mental health in Table  3 .

Mediation and the buffering effect of PSC

The literature consistently confirms the buffering effect of PSC on various outcomes related to worker well-being and mistreatment. Yulita et al. [ 7 ]for example, found that in a high PSC context, job resources had a stronger impact on reducing psychological distress. Similarly, Lawrie et al. [ 41 ] demonstrated positive impact of job control on worker mindfulness which is enhanced in a high PSC work environment. Besides, Siami et al. [ 40 ] revealed that the association between supportive leadership and personal hope is strengthened in the presence of a high PSC. Hall et al. [ 42 ] showed that the effect of job demands on depression is diminished when workers perceive high PSC. Additionally, Loh et al. [ 43 ] found a negative impact of emotional demands on psychological well-being that is mitigated in a high PSC context.

Furthermore, it is indicated that the adverse association between workplace bullying, harassment, and psychological well-being is attenuated when workers perceive high PSC [ 11 ]. Thus, PSC has the capacity to reduce the impact of workplace bullying on post-traumatic disorder and work engagement [ 12 , 44 ] Kwan et al. [ 39 ] revealed that the positive association between bullying and neglect is diminished when a high PSC is perceived by workers. Moreover, PSC moderates the associations between role conflict and workplace bullying [ 17 ], role ambiguity and workplace bullying [ 17 ] and stigma and workplace bullying [ 15 ]. While a limited research attention is given, a study reported that PSC mediates the association between health-centric leadership and workers’ psychological health problems [ 26 ]. These findings collectively emphasize the crucial role of PSC in mitigating the negative consequences of mistreatment and enhancing workers’ well-being.

Workplace-specific findings

The findings from various studies reveal workplace-specific outcomes related to Psychosocial Safety Climate (PSC). In the education sector in Australia, PSC was associated with a reduction in psychological distress and emotional exhaustion among education workers [ 4 ]. Similarly, in Malaysia, among police officers, PSC buffered the effect of job resources on psychological distress [ 7 ]. Healthcare workers in China experienced a decrease in workplace violence in the presence of a positive PSC [ 8 ]. For the general working population in Australia, PSC was linked to a decrease in harassment, violence, and bullying [ 10 ]. In diverse settings, including police officers, the general working population, and refugees in Australia, PSC demonstrated a consistent negative association with workplace mistreatment such as bullying, harassment, violence, discrimination, and abuse [ 12 , 13 , 18 ]. Healthcare workers in both Australia and Malaysia reported improved psychological well-being in the presence of a high PSC context [ 19 ]. Construction workers in China showed enhanced mental well-being [ 20 ]. Various workplace settings, such as attorneys in the USA and oil and gas workers in Malaysia, exhibited a decrease in psychological distress with a positive PSC [ 27 , 28 ]. Notably, healthcare workers across different countries, including Iran, Australia, and Canada, experienced positive outcomes such as decreased emotional exhaustion and stress, emphasizing the universal impact of PSC in healthcare settings [ 22 , 30 , 35 ].

This review found that PSC has a negative association with workplace mistreatment such as bullying, harassment, violence, discrimination and abuse. Furthermore, we found that PSC has a positive association with psychological well-being, personal resilience and hope. Moreover, PSC has a negative association with psychological distress, stress, depression, cognitive weariness and emotional exhaustion. The buffering effect of PSC is well-established in the literature.

PSC has a negative association with workplace mistreatment. A high PSC work environment indicates that managers and supervisors are perceived as supportive, approachable and caring towards their workers. In such a work context, workers are more likely to feel protected, valued and respected [ 5 ]. Furthermore, such work context acts as a deterrent to workplace mistreatment including bullying and harassment because workers are more assertive at work [ 18 ]. Furthermore, when workers perceive their supervisors as supportive, they are likely to develop trust and respect among workers and towards their supervisors. This trust and respect may lead to positive interpersonal relationships between supervisors and workers, fostering a sense of fairness, partnership, and open communication [ 10 , 11 ]. In such a work context, discrimination and mistreatment are less likely to occur, since they contradict the principles of trust and respect. In a high PSC context, managers and supervisors are expected to exhibit positive behaviours to serve as role models for their colleagues and subordinates. When managers and supervisors exhibit respectful and inclusive behaviours, it serves as precedents for acceptable conduct at the workplace, reducing the occurrence of mistreatment [ 8 , 10 ]. In a high PSC work context, bottom-up communication is encouraged and supervisors are more likely to intervene and address workplace mistreatment, provide training on respectful behaviours and establish mechanisms for reporting incidents [ 5 ]. These communication and conflict resolution mechanisms do not only deter mistreatment but also provide a sense of security for workers.

Influence of PSC on mental health

PSC has a positive association with psychological well-being. In a high PSC context, workers are trained and encouraged to utilise essential resources capable of helping workers to cope effectively with the psychological and emotional demands of work. Furthermore, high PSC implies that supervisors provide emotional support, understanding and validation of their workers which helps buffer against stressors at the workplace [ 5 ]. Besides, the presence of supportive supervisors or management contributes to workers’ mental well-being by reducing feelings of isolation, enhancing self-esteem, and promoting a sense of belongingness [ 7 ]. Moreover, in a high PSC context, supervisors are more likely to be responsive to workers’ needs and concerns, providing workers with essential resources and guidance that alleviate psychological distress [ 33 , 34 ]. Thus, high PSC contexts encourage and empower workers by promoting assertiveness, resilience, and hope [ 39 ]. In such an environment, workers may feel more confident in expressing their needs, standing up for themselves, and seeking solutions to challenges. Consequently, this may lead to increased assertiveness, better coping mechanisms, and a more positive outlook on work-related issues [ 39 ].

The finding that the negative association between PSC and depressive symptoms is stronger for females than males highlight the potential of gender differences in the impact of PSC on mental health outcomes. This finding could be influenced by several variables including differences in socialisation, communication styles, and the importance of supportive relationships for women [ 36 ]. However, further research is needed to explore these gender-specific dynamics in more detail.

The buffering effects of PSC

In a high PSC environment, job resources including job control and supportive leadership, are perceived as more beneficial and impactful [ 5 ]. Thus, PSC acts as an amplifier, enhancing the positive effects of these resources on workers’ mental well-being [ 43 ]. When workers perceive a supportive work environment, they are more likely to utilise job resources that are more effective in reducing psychological distress, increasing mindfulness, fostering personal hope, and mitigating the negative impact of job demands on depression and emotional exhaustion [ 7 ]. A high PSC context would create a sense of psychological safety, where workers feel comfortable expressing their concerns, reporting mistreatment, and seeking essential support [ 5 ]. This situation creates an environment where bullying, harassment, and other forms of workplace mistreatment are less tolerated, and thus, less occur [ 4 ]. The perception of high PSC buffers the adverse effect of workplace mistreatment on psychological well-being, post-traumatic disorder, stress, cognitive weariness and other psychological health problems to improve productivity and organisational image [ 4 ].

PSC in specific workplaces

The workplace-specific findings underscore the intricate interplay between PSC and various professional domains, shedding light on the nuanced dynamics within diverse work settings [ 12 , 35 ]. In the education sector, the observed reduction in psychological distress and emotional exhaustion among education workers in the presence of a positive PSC speaks to the profound impact of a supportive climate on educators’ well-being [ 4 ]. This suggests that cultivating an environment where educators feel psychologically safe translates into not only improved mental health but also potentially enhanced teaching effectiveness. Similarly, the buffering effect of PSC among police officers in Malaysia, mitigating the impact of job resources on psychological distress, implies that the nature of law enforcement work may be less psychologically taxing when embedded in a supportive organisational climate [ 7 ]. This finding holds implications for law enforcement agencies globally, urging a closer examination of the organisational factors influencing officers’ mental well-being.

In healthcare settings across different countries, the consistent positive outcomes, including decreased emotional exhaustion and stress, emphasise the universal importance of PSC in fostering a supportive environment for healthcare professionals [ 22 , 30 , 35 ]. The demanding and often emotionally charged nature of healthcare work makes the role of PSC in enhancing mental well-being particularly crucial. In the context of the general working population, the findings of reduced harassment, violence, and bullying in Australia underscore the broader societal impact of promoting a psychosocially safe work environment [ 10 ]. These results imply that organisational climates that prioritise employee well-being contribute not only to individual flourishing but also to creating healthier workplace cultures that extend beyond specific professions.

The enhanced mental well-being observed among construction workers in China suggests that the positive effects of PSC are not confined to traditional office settings [ 20 ]. In physically demanding and high-risk occupations, cultivating a supportive climate may play a pivotal role in mitigating the adverse psychological impacts of the job. Furthermore, the positive outcomes observed among attorneys in the USA and oil and gas workers in Malaysia highlight the relevance of PSC in diverse and high-pressure work environments [ 27 , 28 ]. The findings imply that irrespective of the industry or professional demands, a psychosocially safe climate can act as a buffer against psychological distress.

Practical implications for managers and organisations

Organisations and managers need to cultivate a supportive leadership style that emphasise open and bottom-up communication, approachability, and empathy towards workers [ 44 ]. Building positive relationships with workers and demonstrating genuine care is enhance PSC which contributes to creating a healthy and decent work environment where the psychological well-being of workers is prioritised. Furthermore, organisations should establish clear policies and procedures that explicitly address workplace mistreatment such as violence, bullying, harassment, discrimination, and abuse. These policies should be effectively communicated to all workers, reinforced and encouraged through training programmess. Organisations emphasising a zero-tolerance approach to workplace violence and harassment, have the potential of promoting a culture of respect and fairness, thereby promoting the health and well-being of their workers [ 45 ].

Managers and supervisors ought to undergo training on the significance of PSC and its relation to preventing mistreatment at the workplace. This training should concentrate on augmenting supportive leadership skills, promoting positive communication, conflict resolution, and creating an awareness of the impact of mistreatment on both individual and the organisation [ 46 ]. It is of utmost importance to institute confidential mechanisms for workers to report incidents of mistreatment without any apprehension of retaliation. Encouraging reporting can help identify and address mistreatment cases expediently. Managers should communicate the existence of reporting channels and ensure that workers feel secure and supported when reporting their concerns and seeking support and resources.

Managers possess a vital function in establishing a culture that highly regards respect, diversity, and inclusion. Through the cultivation of an inclusive work environment, wherein individuals are treated with dignity and fairness, managers can contribute to creating a high PSC context that minimizes the occurrences of mistreatment [ 46 ]. Managers should consistently evaluate and attend to work-related stressors that may lead to psychological distress, cognitive fatigue, emotional exhaustion, and depression. This can encompass the management of workload, provision of resources and support, and promotion of work-life balance. Organisations ought to allocate resources to workers’ well-being initiatives, such as mental health programmess, wellness activities, and workshops that develop resilience [ 46 , 47 ]. Such initiatives may further reinforce psychological well-being, personal resilience, and hope among workers.

Limitations and recommendations for future research

Most of the studies included this study were cross-sectional surveys which are usually affected by response bias, which may also affect the findings of this review. Using only papers published in the English language may affect the volume and depth of evidence retrieved for this review. There is limited evidence from continents such as Africa and South America that may skew the findings. However, authors used robust protocols to retrieve essential papers from 13 countries, screen papers, extract data and thematic analysis which may help in generalisation findings and make recommendations for future research and practice. Authors did not appraise the studies included in this scoping review. This poses a limitation as it may impact the overall quality and reliability of the included studies. Hence, caution should be taken when interpretating the findings and conclusion drawn from this review. Further research is needed to explore gender-specific dynamics in the influence of PSC on workplace mistreatment and mental health. A future systematic review is needed to estimate the practical effect of PSC on psychological well-being and workplace mistreatment.

This review found that PSC has a negative association with workplace mistreatment such as bullying, harassment, violence, discrimination and abuse. Furthermore, the authors found that PSC has a positive association with psychological well-being, personal resilience and hope. PSC also has a negative association with psychological distress, stress, depression, cognitive weariness and emotional exhaustion, strongly establishing the buffering effect of PSC on worker health and well-being. The findings highlight the importance of fostering a supportive work environment and cultivating positive relationships between supervisors and employees. Workplaces or organisations should prioritise the training and development of supervisors to enhance their supportive skills, encourage respectful behaviour, and provide guidance on conflict resolution. By promoting a high PSC context, organizations can create a culture that discourages mistreatment, leading to increased employee well-being, job satisfaction, and productivity. Finally, organizations need to address factors that contribute to low PSC, such as ineffective leadership, lack of open bottom-up communication, or perceived unfairness. By identifying and addressing these issues, organisations can make practical steps towards creating a work environment that minimises mistreatment and promotes a positive workplace culture. Further research is needed to explore gender-specific dynamics in the influence of PSC on workplace mistreatment and mental health. A future systematic review is needed to estimate the practical effect of PSC on psychological well-being and workplace mistreatment in various and diverse organisational settings, especially in settings such as Africa and South America that have received limited research on PSC and its interplay with workplace mistreatment and mental health.

Data availability

All data generated or analysed during this study are included in this article and its supplementary file (Table S1 ).

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Acknowledgements

Authors are grateful to graduate students at the Department of Health, Physical Education and Recreation, University of Cape Coast, for their enormous support. Authors are also grateful to the chartered librarians at the research commons and digital library units at the Sam Jonah Library, University of Cape Coast for the support.

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E.W.A and M.A conceptualisation and design the study. M.A conducted data collection and analysis and initial write-up, M.A and J.O.S independently extracted data for evidence synthesis, reviewed by E.W.A. M.A wrote the first and final draft. M.A and E.W.A examined and oversaw the review process. The final draft of the manuscript was read and authorised for publication by all authors.

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Amoadu, M., Ansah, E.W. & Sarfo, J.O. Preventing workplace mistreatment and improving workers’ mental health: a scoping review of the impact of psychosocial safety climate. BMC Psychol 12 , 195 (2024). https://doi.org/10.1186/s40359-024-01675-z

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DOI : https://doi.org/10.1186/s40359-024-01675-z

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Healthcare workers seek help preventing violence in the workplace

W ASHINGTON (NEXSTAR) – It’s dangerous to work in a hospital and it’s not just because of germs or viruses. Hospital workers across the country are increasingly the victims of violence.

“Verbally assaulted. We’ve been hit, slapped, kicked, punched. Having our own equipment thrown at us,” Emergency Nurses Association President Chris Dellinger said.

Dellinger and other healthcare leaders came to Capitol Hill and spoke about the difficulties healthcare workers are facing.

“We no longer are just a place of healing because now we have to worry about our own safety and our other patients’ safety as well,” Dellinger said.

A 2018 report from the U.S Bureau of Labor Statistics said healthcare workers were six times more likely to be attacked in the workplace than other private sector workers.

“Since the pandemic, we’ve actually seen an increase in violence,” Dellinger said.

Katie Boston-Leary with the American Nurses Association says these cases are frequently going unreported. She is calling on Congress to pass two bills to address the issue.

“We’re pulling the alarm right now, that this is something we have to contend with right now,” Boston-Leary said.

One bill would make violence against healthcare workers a federal offense. The other creates a federal standard for hospital safety and offers protection for employees who report incidents.

“Even if we move the dial 20% from where we are today, it would be huge, right? We’re not looking for a 100% solution right away, because we know that this is a multi-layered, complex issue,” Boston-Leary said.

Healthcare experts fear, if nothing is done, the uptick in violence will cause more nurses to leave the profession.

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Welcome to the month of April, Workplace Violence Prevention Awareness Month! This month, we’d like to share a video about Workplace Violence that discusses the history and good information regarding the topic. UC Davis Health is setting the trend in Workplace Violence with all the tools and resources we have to offer.  In addition to the video, we will be making rounds at the hospital and our local clinics to share more information about our team and solicit feedback regarding our program. We want to make it the best of the best! 

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https://ucdavis.box.com/s/qbrnyvemu909czjkdqhe7x1utfazubiq

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